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dt, c�,�s� Cly sva�s�fe/jkli <br /> fAeL 7i off�rono <br /> °1 Building Permit Application esc r J c_-�b2 OO <br /> for New Structures or Additions a - '0- P 110 <br /> Mailing Address: Permit number: ,212 /0—ba/Of <br /> ‘-lt)C).-ViO <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: o2/a57/0 <br /> '4°''' <br /> '. s. Street Address:. Received by: <br /> l'*.; ,l ilci G�ti 2750 Kelley Parkway Plan review fee: �:3o/�, F9 <br /> 9kEsHOg� Orono, MN 55356 o2 )/U -o7`O <br /> Total Fee: ! <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us k. <br /> This application form must be completed in full and all required information must be submitted. _ 7 <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: aa- 15 , • yf <br /> Job Site Address: • • .. • ► `� <br /> 70L1/4N tt§ . <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes gc 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: J o s OA Lik- (amu A/ far- So N etc A CA'ftTE.1o1 'E Z S'AK— <br /> State License# .toss 603'4 Expiration Date: <br /> Phone: (office) 7-W5 ,gaci .540q (cell) <br /> Mailing Address: I/s-55 T-4{RzGI /kale Sc- City: BuccPtt.o ZIP: 4'5313 <br /> Contact Person: Tos>'tur Kb 151,I Applicant is: Qontrac oD / Homeowner (circle one) <br /> Email and/or Fax: Jomocac.A RPew-a rc e. cx-rESCA .C-o yv` <br /> PROPERTY OWNER INFORMATION: I <br /> Name: Mtts . Sho-rD►J Av, %tbv�el <br /> Phone (day): eisa. 9 -c. R10(0 HM cisd•(03. 5-310"IJ)c..ok" call <br /> Address: let o i i t'o w)3 iz, City: °ROW) ZIP: 5'535(0 <br /> Email and/or Fax N;e.okya+Rcrliey\ .1ahba,cowt <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: e I, k.. S1,.‘i,1 I awok- <br /> Phone (day): 4(40 . 353-11a <br /> Address: ISO Monroe-St. of Ila City: Rocku,tic AUlb ZIP: aogSU <br /> Email and/or Fax: d,sa)nap ic.kthys e. oxnai I; .e.bw. <br /> des;g.1..1Chfhyse gw,a;I-cow <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal & <br /> ® New Construction Water Supply <br /> ® Single Family with ® Residence <br /> ❑Addition attached garage ❑ Garage/Accessory <br /> ❑Accessory Building ❑ Single Family with DI Deck <br /> Bldg. ❑ Public Sewer <br /> ❑ Relocation detached garage ❑ Office/Commercial <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ® Private Sewer <br /> P ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> '`*Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial CR'Private 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) $ )0CSO <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />