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1, V,,'' � 1� <br /> `t y <br /> City of Orono 7�, r75 <br /> Building Permit Applicatio <br /> for New Structures or Additions <br /> Mailing Address: Permit number: a0/ t�O/3 7 <br /> 0 PO Box 66 <br /> v0 Crystal Bay,MN 55323-0066 Date,received: '—/ —/h/ <br /> Street Address:' Received by: I'� <br /> A2750 Kelley Parkway Plan review fe: 97 3�� <br /> *1\11E- <br /> c? Orono,MN 55356 O7 <br /> KfSHOv-t Main: 952-259-4600 Total Fee: <br /> Fax: 952-249-4616 www.ci.orono.mn.us t 5Ck' aN l'--1 <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: ,. /0 -.--/k 1 -JT <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes Elisio <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: Li ' ?vt L l C, TAR_ <br /> License# eL ©, 3 a.'t Expiration Date: ....0_01.< <br /> Phone: (cell) �/1.- c,S5- '7O (office) <br /> Mailing Address: 8 a y / "err Av4 Cit :t 4,44,4% ZIP:.5.6,- _53 <br /> Contact Person: L, ; " . • =. _ Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: 7 k uI ef`t e,�f., v u, .., <br /> PROPERTY OWNER I FORMATION: <br /> Name: PLNAEL_ / Jc lJ <br /> Phone (day): WYa• aqW - /a-oz) <br /> Address: .3$1S �/etj-,.d (),e, City: O,e;oNo ZIP: <br /> Email and/or Fax ; ` SA'ens a;deA-I.r`1y..c ,6zM 9...S" - q-73".. ( 4 <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: , R0u: LrNeap <br /> Phone(day): "763 - a 3 S• 9:14‘ <br /> Address: .3R 0'6 6Lc>X�rIA /4 Al City: LilYs%!4< ZIP: -- -S.4.2--) <br /> Email and/or Fax: a— r/ e___r I-v.:,.e 044 <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> 6-Aiddition <br /> ew Construction 0 Single Family with Residence <br /> attached garage Garage/Accessory Bldg. �J Public Sewer <br /> ❑Accessory Building El Single Family with ❑ Deck r <br /> ❑Relocation detached garage ❑Office/Commercial ❑Private Sewer <br /> ❑Other: (specify) 0 Multiple Family/Condo 0 Warehouse <br /> 0 Public 0 Storage 1g Public Water <br /> **Any earth movement may require ❑Commercial 0 Other(specify) <br /> MCWD review&permits. 0 Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.m i n nehahacreek.orq <br /> Estimated Construction Valuation (excluding land) /, 5/at UGO "`-- -- <br /> Packet <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />