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City of Orono )-6 <br /> ,k(-\ <br /> Building Permit Application 94' <br /> for New Structures or Additions <br /> Mailing Address: Permit number: c! O I a. - 4 0 3 7 9 <br /> x`"10 PO Box 66 ` U <br /> Crystal Bay, MN 55323-0066 Date received: `J-0 -1 2-- <br /> t �, Street Address:' Received by: <br /> �' , I �ja"/ tiF 2750 KelleyParkway <br /> t I; ,�o Orono, MN55356 Plan review fee: 317. 3,6 <br /> �EeHo�' ao l a -00,3 7 g <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: 4- c, lv&-Fe---j4j-w ji-jp <br /> �1 `e 7)6_./1, 3 �' <br /> Will this be a Parade of Homes, Remodelers Showcase Home'or oth' r Display Horde? ❑ 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: 5heOmc�-vl �,ulibc�Y' .1-#16., ` <br /> State License# 'Y. /9 Expiration Date: 3`3/ /1 `-- <br /> Phone: 300-- 679-3'/3,, 16/24officif3 7- 6,3-0/ 3a ..-,30 -4f/66 (cell <br /> Mailing Address: ,3F //ivy �,S /4-2— / �., , -f City: /i?ci-'/ eR SSo->%/ S 3, <br /> Contact Person: /'4,;,n13%;55 fr Applicant is: Contractor omeowner (Circle one) f' <br /> Email and/or Fax: /'cb,n &Skermc,n�o/J teem /r-" k.:4 , c 1 <br /> PROPERTY OWNS INFORMATIOry <br /> Name: rc\ <br /> Phone (day): G I Z. w7 -- 6 5 t✓ t— <br /> Address: +2 `(5 Wc.4,--{ ,11 12zi, City: q' 4 /)r/ ZIP: 3---c-3,:. <br /> Email and/or Fax r , 8 , tea,,,. 0 y,,, A... 1 , `r;-)v,, ! <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: t(--A - `�' z .5.1 'Pc1. Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal & <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑Bosidence <br /> ❑¢ddition attached garage Ur-Garage/Accessory Bldg. ❑ Public Sewer <br /> DI Accessory Building ❑ Single Family with ' ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ErPTivate 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. ❑ IndustrialPrivate 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.orq <br /> Estimated Construction Valuation (excluding land) $ -3 .2-tO_ cy 0 <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />