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autkA31/z) <br /> City of Orono <br /> Building Permit Application4 1,0,6]for New Structures or Additions 3r7- °Z-5 <br /> g OA?- 0) <br /> Mailing Address: <br /> ox 66 Permit number: 2-b/ 0 -OOe 7Q <br /> Crystal Bay, MN 55323-0066 Date received: 7 /5//o <br /> EssReceived by: __(,,,,r TA ,,,, Street Address:' <br /> CC'4r:ii. ,, 2750 Kelley Parkway ZD 10-.O041131 n review fee: as o . 6/ va <br /> Orono, MN 55356 <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: itil Zb V)471-0.-} A_ , Droftaz, ScSSi <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ 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 n,be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: n <br /> Name: r - - y <br /> S -e Y-�� h'. ' ��J1 ( 0 <br /> State License# 7 -I p Expiration Date: 21 3 i 1-7_Of ( ) <br /> _ Phone: tp- 2 g _ Li �� <br /> 3 (office) S 6,mil.- (cell) <br /> ' Marling Address: 14"]U r•e er City: n Y ,- ZIP: ' 7 o0 k <br /> Contact Person: --t- v �+, . ... <br /> �,,.�.�,. ; . 4,-V �-,-_�-�- Applicant is: Contractor / e ner (Circle One) <br /> Email and/or Fax: E ,.z� 3 SLyYv., <br /> PROPERTY OWNER I ORMATION: <br /> Name: r44"- ,� _ <br /> Phone (day): 41-"2,- l44,1 ,. ' <br /> Address Air. i Cit : ZIP: % 3 <br /> Email and/or Fax CrJ <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: fA.e r fk ` <br /> Phone (day): -1 G 1 -S H t- O( C50 <br /> Address: L D0 Wc.,,.-?c 'a\,1‘k. City: Gam\bl.er. ic.tk\ZIP: 5T1. L <br /> Email and/or Fax: 141- t,,1 i 1341 <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> 4 <br /> ew Construction ❑ Single Family with El Residence <br /> Addition attached garageara e/ • cessory Building ❑ Single Family with ❑0DgDeckBldg. ❑ Public Sewer <br /> ❑ Relocation detached garage 0 Office/Commercial <br /> ❑ Private Sewer Other: (specify) 0 Multiple Family/Condo 0Warehouse <br /> o Public 0 Storage 0 Public Water <br /> **Any earth movement may require 0 Commercial 0 Other(specify) <br /> MCWD review&permits. 0 Industrial XPrivate Well <br /> Minnehaha Creek Watershed District(MCWD) la Other: (specify) <br /> 18202 Minnetonka Blvd A►ti'�+ <br /> � <br /> Deephaven, MN 55391 PoLt 3�C�rl►j <br /> Phone: 952-471-0590 p IW red�.. <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ -` <br /> 66-6 <br /> Last Updated: 9/29/2009 �' i, ��) <br /> - 17- <br />