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• <br /> ' City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> �'�0,� PO Box 66 Permit number: Z(7/ 0 —00470 <br /> Crystal Bay, MN 55323-0066 Date received: $ /500 <br /> A '441`!: Received b <br /> .01,,;' �. Street Address:' y: IT • <br /> - <br /> ��'�L t,igi '.�p�- 2750 Kelley Parkwaypd2O /CI 6°4(17%n review fee: '� c''c O S1'vi CC' <br /> sxo� Orono, MN 55356 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: <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: c7.11 ki-ioA_ r ® 1S <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes rk 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 w�i%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: 5 - s -�r'� h', t pf t l 6v\ <br /> State License # '7 cm Q Expiration Date: 3 i 3► j'ZO( <br /> Phone: V3- - a - Li '-c,3 (office) S 6.,,,t.s� (cell) <br /> • ' `Mailing Address: 1V-1 t) ,--e rr City: ZIP: <br /> Contact Person: v- ��' �rr � � ���''��`� S��`t <br /> • ` it ,\7•� .�- ; •- Applicant is: Contractor / e caner ,(circle One) <br /> Email and/or Fax: ' '(, ___ 1 a C�. <br /> f' ' � ' C -1 ate. ` �� <br /> PROPERTY OWNER I ORMATION: , . <br /> Name: <br /> Q 'e�Phone (day): . ,. <br /> Address: l ` City: Ority ZIP: S-f-3 <br /> Email and/or Fax e-k.e. W `� �' i <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: At ra — S <br /> Phone (day): i_ <br /> 4 Z --S ti t- C( -r' <br /> Address: <br /> AddrEmailandJor Fax: G V1L. Wi-,\-?(-4-e, ` i.IA- City: Wt,Lcv. l'c,t({\ZIP: 'S-S-4.-Z-4 <br /> X43 - 1t I -LI/ <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal & <br /> ew Construction Water Supply <br /> ❑ Single Family with ❑ Residence; <br /> Addition attached garage Gara e/ • cesso Bldg. <br /> Accessory Building �- g ry ❑ Public Sewer <br /> ❑ Single Family with ❑ Deck - <br /> ❑ Relocation detached garage E Office/Commercial <br /> ❑ Other: (specify) ❑ Private Sewer <br /> ❑ Multiple Family/Condo 0 Warehouse <br /> ❑ Public ❑ Storage 0 Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review & permits. E Industrial Private Well <br /> Minnehaha Creek Watershed District(MCWD) „Other: (specify) <br /> "�++ <br /> 18202 Minnetonka Blvd ®tSt- ektti <br /> Deephaven, MN 55391 P <br /> Phone: 952-471-0590 p u.re®W <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ a`�,U` <br /> Last Updated: 9/29/2009 'j`d "' �� <br /> - 17 - <br />