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4 <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions $`02731,75' <br /> Mailing Address: Permit number: �,Cscf -C C 7'5'; I <br /> O 0 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: (� 1`-� ��� <br /> Receiv d by: it 1F <br /> ,� �� Street Address:' ���/yZ � <br /> ��,� i�jiA.1-4:i 2750 Kelley Parkway 121=C'c\f - 0( la review e i���c�( • g9 Pt <br /> ikesOrono, 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: 70 WFi4 R Li4.vE S. <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes SI-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: GoRbo•iJ Sol of 5 CoousTI (AcTZo•% <br /> State License# o?OS3 ici(o I Expiration Date: "Meg aol0 <br /> Phone: (?.3)409 -3t 17 (office) (cell) <br /> Mailing Address: 5/S9 #/ftiev 51, E Po.Box loc. CittL,fMPiE PtiIry ZIP: 8.8389 <br /> Contact Person: -ToE rncpmEaso,✓ Applicant is:(Contractor / Homeowner (Circle One) <br /> Email and/or Fax: Joe- gordcN- i wits. cowl Z743)4179- alar <br /> PROPERTY OWNER INFORMATION:J <br /> Name: Sr} 4 �' uS to <br /> PFEXFFE <br /> Phone (day): (asiy'7 . a-a?I LI <br /> Address: City: ZIP: <br /> Email and/or Fax joai jwso., Q yakoo . co wl <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: co4o.,,VAbI' 13S 51 60v 61eou P <br /> Phone (day): (MO 42o - g5.43 <br /> Address: /86,53 ?ovthE/CosA L'T. City: EAE., Pk,.tyesE ZIP: 55347 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> IgNew Construction jg Single Family with JS'Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage El Office/Commercial iJ Private Sewer <br /> ❑Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial El Other(specify) <br /> MCWD review&permits. ❑ Industrial g 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) $ 3.5-o,00,0 — <br /> Last Updated: 5/21/2009 <br /> -20- <br />