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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> -: Mailing Address: <br /> 0 PO Box 66 Permit number. V T <br /> Crystal Bay,MN 55323-0066 Date received:Received by: <br /> ;; Street Address:' <br /> 0 2750 Kelley Parkway <br /> Orono,MN 55356 Plan review fee: At <br /> Main: 952-249-4600 Fax: 952-249-4616 www.cl.orono.mn_us Total Fee: <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: <br /> Incomplete applications will be returned. (Please print) <br /> , ,R <br /> Job Site Address: `f `j �'I w. r r. R <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? LJ Yes No <br /> If yes,a specie/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will bw,-' <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �fj(<. � .r.nCAI <br /> .,4. <br /> State License# -.;)L 03 X31 '~ to Expiration Date: - Z d r 3 <br /> Phone: Ln t Z--Le 140- 4 4-4,-4 7 (office) .-- -. (cell) <br /> Mailing Address: t 5 ?�o F IS+1, t mac,t e '%G City' i�*DoT C�,j<eZIP• R> 3 > Z <br /> Contact Person: )d f Ctstr y ; ,,.! r Applicant is: Contractor.,,/ Homeowner tcird9 on.l <br /> Email and/or Fax: Jc�P. r3r vC►rt <<' w14 <br /> PROPERTY OWNER INFORMATION: <br /> Name: L h r<f�,/� 'r•1/, , <br /> Phone(day): i :. 4' . C,, ✓O. 11 z 2.. fi <br /> Address: -4A City ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> ❑ New ConstructionWater Supply <br /> Q Single Family with El Residence <br /> ®Addition attached garage ❑Garage/Accessory Bldg. ❑Public Sewer <br /> []Accessory Building ❑ Single Family with 0 Deck <br /> ❑ Relocation detached garage ❑Office/Commercial El <br /> ❑ Private Sewer <br /> Other: (specify) ElMultiple Family/Condo 171Warehouse <br /> ❑ Public ❑Storage ❑ Public Water <br /> "Any earth movement may require ❑Commercial ❑Other(specify) <br /> MCWD review&permits. ❑ Industrial <br /> MCWD El Private Well <br /> Minnehaha Creek Watershed District <br /> ( ) El (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> wavw.mirn i h creek.cr <br /> Estimated Construction Valuation(excluding land) $ <br /> r <br />