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City of Orono <br /> Building Permit Application 7!5- <br /> for New Structures or Additions <br /> Mailing Address: \ <br /> O.g,O,�O PO Box 66 <br /> Permit number: <br /> aoia -00.33 9 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Street Address:' Received by: <br /> 2750 Kelley Parkway Plan review fee: o,70/cP -6D3 <br /> �9kE3H0�� Orono, MN 55356 /73Z-4y <br /> CG <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: * V5 V AXk_tX bL4N f-OVW <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes El 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 I APPLICANT INFORMATION: <br /> Name: -5ftw&-o4US ( Nc- <br /> State License# Fk' 00 2,30"z Expiration Date: <br /> Phone: 7o3•-533'0 3 05?- office cell <br /> Mailing Address: -F W Cit INS nXZk,� ZIP: k5ZZ <br /> Contact Person: 1" r-'Lt--e Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: r(4-_I' injko 5`'W PsE lAe,,3 't <br /> PROPERTY OWNER INFORMATION: <br /> Name: M 4 _�I t,L <br /> Phone (day): 1raZ- 4Zf0- (0030 <br /> Address: 41t, WAWyLAb,-JrJ TWO City: 6(1.ONC ZIP: 553A5cl <br /> Email and/or Fax MIp'(L`iZ� 6 <br /> ARCHITECT I 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 /> 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 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 /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ wl000 <br /> Packet Last Updated: 10-20-2011 <br /> -20 - <br />