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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> 4W. V PO Box 66 Permit number. �`)/ 7—XL/4 <br /> !i► Q Crystal Bay, MN 55323-0066 Date received: "5-•- /7 - / 7 <br /> ` Street Address:' Received by: / ,�1 f <br /> 42750 Kelley Parkway <br /> "S'<, r� Plan review fee: l �"— k=F �,� i2 <br /> L Orono, MN 55356 <br /> !'xESHO�� Main: 952-249-4600 Total Fee: 1 <br /> Fax: 952-249-4616 www.ci.orono.mn.us /� ; �5 <br /> This application form must be completed in full and all required information must be submitted. _ r, <br /> Incomplete applications will be returned. (Please print) (f rn s mit ,ii <br /> GENERAL INFORMATION: <br /> Job Site Address: c Ti "� 55:3- 6C �~� <br /> �t2J lit.. V itry �-e ,'C r)ND , Biu - <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes D 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 wilt 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: L pjc. /CCN I a Sr7EC:;0"1-tsfis NIti <br /> State License # Expiration Date: <br /> Phone: (cell) 612— 221 — s_"-73 (office) <br /> Mailing Address: 52-75 LcGoa Ir niA,,,inai d, I 20-- City: Lc, Irak._ ZIP: ,_-5(-B1 <br /> Contact Person: Applicant is: Contractor (omeowrier-) (circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION; <br /> Name: MPC Vrt�1ti' 7tclV I.;t r' 1''. I\N C ' .S-C <br /> Phone (day): C5Z-221 -t-1-c152 <br /> Address: 1125 Awa V I Ev i -pc. City: Sa No ZIP: 4,1-,5":4-4_, <br /> Email and/or Fax 11)1LiiSt_ l-Ca CyIIL UL.cocn <br /> ARCHITECT / ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: 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: Description of project: P - ( '�, ,r�r � r '1 '`1 <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Construction Water Supply <br /> Single Family with .Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑ Public Sewer Accessory Building 0 Single Familywith 0 Office/Commercial <br /> ❑ Relocation detached <br /> garage 0 Residence Septic <br /> ❑ Other:(specify) 0 Multiple Family/Condo 0 RetainingWall(s)Wall( ) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> **Any earth movement may require 0 Commercial 0 Storage <br /> MCWD review& permits. 0 Industrial 0 Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) ja0ther(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 <br /> 0 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> 7e0C I FAN-i I I l'Orl <br /> Estimated Construction Valuation (excluding land) $ j J 1900 6vPacket Last Updated: January 2016 I <br /> Page 21 <br />