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City of Orono <br /> Building Permit Application i <br /> for New Structures or Additions <br /> _ Mailing Address: Permit number: Q/ —(gyp 7/ <br /> ej, PO Box 66 <br /> %O O Crystal Bay, MN 55323-0066 Date received: 9-Z� <br /> i �. <br /> Street Address: <br /> Received by <br /> 2750 Kelley Parkway �r Plan review fee: <br /> \t9 �sFio4// Orono, MN 55356 <br /> Tota <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (L-0 <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �(M UTAr '`fQI• p f Co 0 ro no <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ANo <br /> If yes a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will 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: eS5/64, <br /> State License # OC(P391a7 Expiration Date: 3 ''31—/ <br /> Phone: &1X_1_; /0-5N9 C__1/ (office) (cell) <br /> Mailing Address: 0V'7:; `A 11 . City.. 'ice' ZIP: <br /> Contact Person: �A-W'; rA&$S/6V,, Applicant is: ntractor / Homeowner (circle One) <br /> Email and/or Fax: C*kf <br /> PROPERTY OWNER INFORMATION: <br /> Name: cigrk. S syvtl`l(x <br /> Phone (day): I52-913-7,,rYV <br /> Address: w¢ ot,1A RO. city: f ZIP: S53S�O <br /> Email and/or Fax COM <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 i 4. Sewage Disposal & <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence <br /> ❑ Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial El Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial Other(s ecify) <br /> MCWD review& permits. ❑ Industrial Private Well <br /> Minnehaha Creek Watershed District(MCWD) [ Otn9r: (specify) <br /> 18202 Minnetonka Blvd (7OM Slaeo <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 l2 x 16 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.org NN <br /> Estimated Construction Valuation (excluding land) $ ©y t/ . <br />