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City of Orono <br /> Building Permit Application ' <br /> for New Structures or Additions VOt <br /> t <br /> Mailing Address: Permit number: c„? /7 "Q JO `Te <br /> A PO Box 66 <br /> / ���VO Crystal Bay, MN 55323-0066 Date received: 9-/7 —/ V <br /> Street Address:' Received by: <br /> �. 2750 Kelley Parkway Plan review fee: <br /> 6� �� Orono, MN 55356 <br /> N1KESHo�� Main: 952-259-4600 Total Fee: <br /> 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: --13i 5 \\(ec-v Nsi C <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes CPjiNlo <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 INFO�RMATJON: , <br /> Name: M\N� �'\ Na..),\A ( :44\ Date: <br /> State License# Expiration <br /> Phone: (cell) `I'S 2 c(i3- 3.2.-� (office) <br /> Mailing Address: 2.9 15 We_(�v C��aJ) City: OYtY\C, ZIP: 5�-7-6-y <br /> Contact Person: C�� Applicant is: Contractor�Homeo (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: . \c--(--5 -E1 Ny\\C--,2 \,a, ,u\ C (1✓1 <br /> Phone(day): 2 ctt-- 5 2b <br /> Address: iS tiJ .ckY _A `r—CU City: ZIP: <br /> Email and/or Fax Y\ LU�.� v'c:_„i\ . e-Yhe k..{cc L�c:u�, ,CA:Nal <br /> ARCHITECT/ENGINEER INFORMATION: l <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of pro.ect: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal & <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence <br /> ❑Addition attached garage Garage/Accessory Bldg. ❑ Public Sewer <br /> 'Accessory Building ❑ Single Family with ❑ Deck <br /> [' Relocation detached garage ❑ Office/Commercial 0 Private Sewer <br /> ❑ Other: (specify) 0 Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd . -{.6-Ws.3 <br /> Deephaven,MN 55391 <br /> Phone:ax9 -471- 68590 <br /> Fax: 952-471-0682 \N"\Y(' <br /> www.minnehahacreek.orq II hh <br /> Estimated Construction Valuation (excluding land) $ P• <br /> Estimated l <br /> Packet Last Updated: 04/19/2013 " ' ,- 1 <br /> Page 22 of 23 <br /> Nal A ! ' <br />