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i <br /> I <br /> • <br /> ��v <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions Pia-3 <br /> = Mailing Box6ess: <br /> 6Permit number. .20 II- 5-0// 5` <br /> ��O Crystal Bay, MN 55323-006602-h / <br /> Q , � rY Date received: � / <br /> / <br /> Received <br /> i �z,i ;` Street Address:' by: <br /> 2750 Kelley Parkway Plan review fee: 7(0. 70 <br /> rgEHHoif-4,26../ Orono, MN 55356 <br /> � -- 020//-00//z/ <br /> _ <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: 227..--7 6- G✓E=gie-YZ- `4 /(S 4) <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ YesNo <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 e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNERFORMATIO <br /> Name: 1>�1� llwS <br /> Phone(day): G,O.•- ;,& t c — ' 3 l <br /> Address: � -.2 wL.S 6<-41.: �� /� <br /> `Z` S ✓2 ' City: ZIP: ;53-51` <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 /> ❑ New Construction ,,Sin le FamilywithWater Supply <br /> 9 0Residence <br /> iet'Addition attachedara e <br /> Accesso Buildin g g ❑ Garage/Accessory Bldg. Public Sewer <br /> ry g ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial <br /> ❑ Other:(specify) ❑ Multiple Family/Condo 1=1 Warehouse <br /> ❑ Private Sewer <br /> ❑ Public 0 Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) yC ,/ <br /> MCWD review&permits. ❑ Industrial SCdeL ie KPrivate Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: sp ci ) <br /> 18202 Minnetonka Blvd -e---1- R S I`� <br /> Deephaven, MN 55391 ,, nn <br /> ?-k <br /> Phone: 952-471-0590 OA)t.00/S - NG- /✓L' <br /> Fax: 952-471-0682 l ZZ,& <br /> _www.minnehahacreek.orq <br /> Estimated Construction Valuation(excluding land) $ .5 D 00( <br />