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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> PO Box 66 Permit number: pZD /-Oa <br /> Crystal Bay, MN 55323-0066 Date received: 11-0 ' <br /> y- / O, <br /> Received b v� �� ✓�� '., �, Street Address:' <br /> J�tS 2750 Kelley Parkway Plan review fee:9 ^his i0 Orono, MN 55356 <br /> ,.IfESH�.. <br /> Total Fee: <br /> Main: 952-249-4600 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 applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ?0P1S7 wA i <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ® No <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: ?6y0 J,1CHCii2 C <br /> State License# -I0p;7 2-Co Expiration Date: /h� AXH 0012 <br /> Phone: 9SZ—/-i7Z--.S-670 (office) G,/Z-5919—Z/9/ (cell) <br /> Mailing Address: vCp j ly, City: A1929,JD ZIP: 6 <br /> Contact Person: -,V Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: 74L,,0 7C ChTe i1�=C,�S' ,%9h00 <br /> PROPERTY OWNER INFORMATION: <br /> Name: -et ch�9.2p 62,-/�i9,2% <br /> Phone(day): �303 . 6y/ _ 7100?— <br /> Address: Snag- Rz> City: (n,2CjVJC) ZIP: 36rin <br /> Email and/or Fax Rd6 ®�TSSvPI�L�/. Cni,-'l <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZI P: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed use 3.Structure Type 4. Sewage Disposal & <br /> New Construction Single Family with ElResidence Water Supply <br /> Addition attached garage Garage/Accessory Bldg. ❑ Public Sewer <br /> Accessory Building ❑ Single Family with IiDeck <br /> ❑ Relocation detached garage ❑Office/Commercial Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> "Any earth movement may require ❑Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fox: 0.52471-068.2 <br /> www.minnehahacreek.ora <br /> Estimated Construction Valuation (excluding land) $ f�00 <br /> Last Updated: 4/26/2011 <br /> - 19- <br /> Last Updated: 4/26/2011 <br /> -20- <br />