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Pi F4e <br /> City of Orono � • <br /> 16 <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: 11.71:2/1-120/7 <br /> 67w1,41 PO Box 66 3�a <br /> Crystal Bay, MN 55323-0066 Date received: // <br /> Received by: )44-F Street Address:' <br /> 2750 Kelley Parkway Plan review fee: <br /> Esflo�w Orono, MN 55356 f <br /> Total Fee: l g <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:ess: �7 <br /> O -IMV\ ES3�q700uses-V �'�,.‘(�,/•� tit©`v'\t7 <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 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 OWNER INFORMATION <br /> Name: �Co► ��rS6�1o� <br /> Phone (day): <br /> Address: 70 if2 L02.&1— �C - ICU CitC)rQ (pq <br /> Email and/or Fax 95Z X72 17c1 J -�.c c <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 /> 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 —7-1 detached garage ❑ Office/Commercial ❑ Private Sewer <br /> Other: (specify) V%(R•2 ck1('L\ ❑ Multiple Family/Condo 0 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 <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 8 5 d co <br /> Last Updated: 1/26/2011 <br /> - 19- <br />