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City of Orono ,2,5 ` <br /> Building Permit Application 9'1' ,,,\t,''' ''-'\ <br /> for New Structures or Additions <br /> Mailing Address: Permit number: OOI a - 403 7 9 <br /> e4'13.1111 <br /> Cr Bax 66 L <br /> Crystal Bay, MN 55323-0066 Date received: 'J•0—f' <br /> 'tIy <br /> Street Address:' Received by: 6S <br /> ,1 � <br /> ����� 2750 Kelley Parkway Plan review fee: .3{?- 3b <br /> Orono, MN 55356 ao)a -00,37 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-Ze S /3c -feu,- Fel 1 `e P6_11-, -s 3,S-1 <br /> r <br /> Will this be a Parade of Homes, Remodelers Showcase Home/or oth Display Horde? ❑ Yes ZNo <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 /> trai <br /> Name: $LIe,/Nc4-v) 2. bc?' 1/14.1-, <br /> ` <br /> State License# gfel f Expiration Date: 3`3/ // 4- <br /> Phone: 300-- 679-3113g fo Z( 8 7- of�-©/ 3d ...-30V-`i1/4 (cell <br /> Mailing Address: ,3' Mi/ 6S /-4-2i <br /> -- 'ti ; i ,f City: fci1// DAZIP: -.5-0s%/ S S $ <br /> Contact Person: /coke) /3/,5s / / Applicant is: Contractor omeowner (Circle One) I <br /> Email and/or Fax: l"cbin /Sher'r►tc�►-t /): c_�� r�.r, . k_r4� _i , C .1 <br /> PROPERTY OWNE INFORMATION: - k <br /> rk <br /> Name: c <br /> Phone (day): Si"21 - $7 6 s[: 1,3 <br /> Address: +z`t S /:JA ,—i-e-iA.at 4 City:j9 ? )r) ZIP: S 3. <br /> Email and/or Fax r . 8-; kap.. 0 �`a) 1 . rES,&I <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: 1Pc---A`e- ``• % `�' z- . `1 - 1c- <br /> 1. <br /> 1c1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑2Masidence <br /> ❑ ddition attached garageGarage/Accessory Bldg. ❑ Public Sewer <br /> Z Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/CommercialPrivate Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo 0 Warehouse <br /> 0 Public ❑ Storage 0 Public Water <br /> **Any earth movement may require ❑ Commercial 0 Other(specify) <br /> MCWD review&permits. 0 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 02:5-0_ 6-O <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />