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4i o <br /> . , W4-/(kol'I D • <br /> VOID <br /> avt- (P/28'jpi — Dpep' 644-LI om City of Orono 1 J <br /> She r « 4 Building Permit Application <br /> relkovta • for New Structures or Additions <br /> Mailing Address: • Permit number: 0200? -60 570 <br /> 0-1) <br /> Q PO Box 66 <br /> �` Crystal Bay, MN 55323-0066 Date received: 9-q--(2q <br /> A I V;<.� Received by: <br /> jStreet Address:', A ;I2750 Kelley ParkwayPlan review fee: --- <br /> L9kzsiOrono, MN 55356 <br /> Total Fee: 47, <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: ,O GJ6sr 7-,k4w. 6, � kE <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes E--Ko <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: /L( /3 v S 5e1 <br /> State License# Expiration Date: <br /> Phone: 2- lir office cell <br /> Mailing Address: /%0 (,r5. Fo..,...— YeCit <br /> Contact Person: Applicant is: Contractor / omeown r (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: A 5 v S 5 <br /> Name: a�.f14 <br /> Phone (day): 95—'2-- q7(o t / c- 11 3 <br /> Address: „ ,o Q.-4 - 1.4...._ A Cit : Cs-- C L• ZIP: a <br /> Email and/or Fax cS LA./.c.,S&a4"..0 vVIS VA, • 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 /> ❑ ition attached garage oerbarage/Accessory Bldg. ❑ Public Sewer <br /> rii Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial rivate Sewer <br /> ❑ Other: (specify) [' Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review& permits. ❑ Industrialrivate Well <br /> Minnehaha Creek Watershed District(MCWD) .2 her: (specify) <br /> 18202 Minnetonka Blvd 50✓.-'T -e E <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fwax: 952-4minne ahacr 0\-C? <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ IS-- '� <br /> Last Updated: 6/22/2009 <br /> - 19 - <br />