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City of Orono <br /> Building pp Permit Application <br /> for New Structures or Additions <br /> Mailing Address: l Permit number: C7Y_9 r�/5 <br /> PO Box 66 <br /> f V Crystal Bay, MN 55323-00 6 Date received: /- C) <br /> vs- <br /> Street Address:' Received by: <br /> 2750 Kelley Parkwa jy Plan review fee. C7S7 <br /> �e c` Orono, MN 55356 <br /> �k£SHO�� Main: 952-259-4600Total Fee: x bDOd <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 sub ed. c-;s CWW / <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 34 L4 S I&A T E6, T&,ivnJCIA <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes tK No <br /> tf 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: J14VIF-5 CCV3sTR('kcTS0.n/ <br /> State License# t3C- 53184 t Expiration Date: 3.12 c I S <br /> Phone: (cell) 60 -36."1 - 3 7 3 4 (office) 7&3 -4'7 9- _3l t 7 <br /> Mailing Address: 6 BOX 30(0 City: »twPLE P4AX-v ZIP: SS 3 <br /> Contact Person: wok MCP(t-E(zscw Applicant is: ontractor / Homeowner (circle One) <br /> Email and/or Fax: •oe Cet q o.-c-4 o., - t ck—e5 . C <br /> PROPERTY OWNER INFORMATION: <br /> Name: I c o 4,t1A _F_m ,v SoE <br /> Phone (day): 3 4 71 - 3)1"7 <br /> Address: W,X, 3v4, City: l"f1Fic lor_,V ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: E 4 R - �.ve <br /> Phone (day): 0-5.2 7 /` - 77 G <br /> Address: S%Mr:ET City: �'v►:br}ni ZIP: 5535c2 <br /> Email and/or Fax: _ M�kx btl,r c�.^��}in ,,,6 des% :�., <br /> tf <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ,M New Construction )Single Family with ElAccessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage 0 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 Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑Other: (specify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www rninnehahacreek.or <br /> Estimated Construction Valuation (excluding land) <br /> Packet Last Updated: January 2015 <br /> Page 20 <br />