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�Z�'/ <br /> City of Orono $ i,, leo <br /> l <br /> Building Permit Application dam . 3O2° <br /> for New Structures or Additions <br /> Mailing Address: Permit number: 020//01 To2r <br /> O,j� PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: t -6 - // <br /> (4‘',1 • fyStreet Address Received by: S�L +� o~ 2750 Kelley Parkway Plan review fee: 57.53 <br /> \\ zso4� Orono, MN 55356c,,,,,,__-.00./.2_ <br /> l� <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: 2-ct<-15 ( A Iati CA�lJob Site Address: VV <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 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: ° - ► 1 ACL G k '01 r L. ,.C, <br /> State License# a 0• C �`� Expiration Date: 3-3 - `7-, <br /> Phone: -7 - • G I (office) SAM F. (cell) <br /> Mailing Address: -�Q - 1---Vii I ti LA MU Cityg if ( ZIP:55303 <br /> Contact Person: •i f^� - ►1;)�c) Applicant is: o rac d, / Homeowner (Circle One) <br /> Email and/or Fax: . Pty 'V( 1150 L/\-OL o Gfl/'► <br /> PROPERTY OWNER INFORMATION: <br /> Name: SHOO/0 GO WI ON <br /> Phone(day). - .k p <br /> Address: 1.1q--7 - WEAg C-I2(.1,(: City:02 O ZIP:6'6356 <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal & <br /> 4 New Construction Water Supply <br /> ❑Single Family with ❑ Residence <br /> ❑Addition attached garage 0 Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with 0 Deck <br /> ❑ Relocation detached garage 0 Office/Commercial ❑ Private Sewer <br /> [ Other:(specify) (=C.�� 0 Multiple Family/Condo 0 Warehouse <br /> ❑ Public ❑ Storage 0 Public Water <br /> "Any earth movement may require 0 Commercial 0 Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) El 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) $ `A/ 000 r <br />