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City of Orono 4.d <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> PO Box 66 Permit number: <br /> V Crystal Bay, MN 55323-0066 Date received: js /S' <br /> Street Address:' Received by: <br /> Orono, MN 553Kelley Pa5 a o��o0 SJ'7 Plan review fee: s • z <br /> Orono, <br /> 7gkesHo�`� Main: 952-249-4600 P14 e 2 <br /> Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted- <br /> Incomplete <br /> ubmitte Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ZOtt�L-.D <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> ff yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service Wil be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 6G <br /> State License# !aC_3 Z S-,!F;7- Qr- Expiration Date: <br /> Phone cell 7,s (office) Z499 <br /> — <br /> Mailing Address: CityAf 11djacmd ZIP: <br /> Contact Person: &I I-re'r- 134 Applicant is: 1Contracto / Homeowner (Circle One) <br /> Email and/or Fax: _�L��1���r•� „�lJr �p�_ G�.�i4,tC ql�-Z_9r51Z_Gp b� <br /> PROPERTY OWNER INFORMATION: <br /> Name: Q LCG4747W /4?Y.Q 61f 01911.! GS <br /> Phone (day): "Y-6'Z - 2 SS"- 4g/`� �•sI-!� <br /> Address: 2zo City: ZIP: SS`319 [ <br /> Email and/or Fax Ab%2r <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: J4 V1City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> ® New Construction El Single Family with Accessory Bldg./Garage <br /> ❑Addition ' attached garage Deck ❑ Public Sewer <br /> ®Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> "Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> MCWD EJ Private Well <br /> Minnehaha Creek Watershed District <br /> ( ) �Other: (specify) Other(specify) <br /> 15320 Minnetonka Blvd �B C�� C'A/— c <br /> Minnetonka, MN 55345 <br /> Phone: -0590 C fiZ <br /> Fax: 952.471-0-471-0 682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ S <br /> Packet Last Updated. January 2015 <br /> Page 20 <br />