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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: '2-O - Odl —l`� <br /> g,0,4. PO Box 66 <br /> O O \ Crystal Bay, MN 55323-0066 Date received: 1 + Z 31 ect <br /> a I wR s Street Address:' Received by: ��I le cyn '1. <br /> .o.• !„Ai••114 �� 2750 Kelley Parkway Plan review fee: -- ir1G(it ie-c-- <br /> .t ')xo4`+ Orono, MN 55356 <br /> Total Fee: / / 3 r , ''. <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: a i yo w I• c4 e Oak C& �J <br /> Job Site Address: 4( Gee <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes lArNo <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/a �e.IC,��IT INFOFj�MATI � � <br /> Name: ( ' � t...ta v5 <br /> State License# 1 1 Cj� Expiration Date: W�36j�°p <br /> Phone: ''5�—8'g ��a 5— (office) l?-3 _ ' (cell) <br /> Mailing Address: 44)7 . Easf 7 6-c4"---5(- City: ZIP: <br /> Contact Person: u-t,le_ Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: G15 --8-,-6-- ' <br /> PROPERTY OWNE Iy,FORMf�TION: p <br /> Name: v i I�sa-fa'�'-vl g v -. it <br /> Phone (day): 5a, •- vO4'- kayo <br /> Address: 740 Li.) © , C rc4 City: Ufr ZIP: 55.25, <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER NFORMATION: <br /> Name: /'1/-4• <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 /> 2-Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with [a Deck <br /> ❑ Relocation <br /> �` detached garage ❑ Office/Commercial Private Sewer <br /> ,Other: (specify) P ❑ Multiple Family/Condo CIWarehouse <br /> K' 0 ' / 0 Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial ❑ 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) $ �fy(ytj" <br /> - 18 - <br />