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0 1 <br /> / r <br /> i 119$11,0 <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions iiM.00 <br /> Mailing Address: Permit number: 7O 16-D 64,2-2— <br /> 0,4 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: 7Q-2b —/D <br /> �; Received by: !� �-S <br /> A ;,\'fn< A, Street Address:' <br /> 1,4,.t"3,4,;10.' c�`S' 2750 Kelley Parkway Plan review fee: //5 .OS <br /> ikessov-- Orono, MN 55356 ao/p -0062-/ <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: W".G(_5 ,, '}z.)✓-&J fLD oro, P--i-A/ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Ro <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 /> J L <br /> Name: TWO f-0,•-\. (-C. z0-1 5 7t/ <br /> State License# YJ 75 ,cs�) Expiration Date: /1'IGfG 1 <br /> Phone: • office) 2 - � �,-- I till <br /> Mailing Address: 2 41 * Cit : ' ZIP: - <br /> Contact Person: ' f/jG ' 7,S .e,✓ Applicant is: • r- o / Homeowner (Circle o -) <br /> Email and/or Fax: s <br /> PROPERTY OWNE FORMAT,IQN: <br /> Name: k / /-, <br /> Phone (day): 6I 237 Sd f <br /> Address: y 2, cis-- L-1-0`c.-^Je""ni ej C y: Or 0",c) ZIP: ,s5-35---c7 <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: <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. 0 Public Sewer <br /> ❑Accessory Building ❑ Single Family with ( beck--- <br /> 0 Relocation detached garage El Office/Commercial 0 Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage 0 Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ OCa) <br /> Last Updated: 9/29/2009 <br /> - 17- <br />