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CITY OF ORONO <br /> BUILDING PERMIT APPLICATION <br /> FOR NEW STRUCTURES OR ADDITIONS <br /> �O A, Mailing Address:PO Box 66 Permit number: C-)) I 7 C5 2. <br /> j VO <br /> Crystal Bay, MN 55323-0066 Date received: 12 I h <br /> .� Street Address:' tC e_ <br /> 2750 Kelley rk ay -R_o (`_C L�S Plan review fee: (p 3 S <br /> 'FPS H O� Orono, MN 53 <br /> Main: 952-249-4600 Total Fee: <br /> Fax: 952-2494616 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: '] <br /> Will this be a Parade of Homes, Remode s Showcase Home or other Display Home? Yes o <br /> tf 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 1 FORMATION: <br /> Name: s <br /> State License# Expiration Date: <br /> Phone: cell t :?- - office <br /> Mailing Address: 11701 © City: .v,` ZIP: / <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: e,,,� ,,t Govs�► <br /> PROPERTY OWNER INF RMATION: J <br /> Name: g o i f �o✓ r-�Y S rj'V rte-6 <br /> Phone (day): i e1 di 5 <br /> Address: <br /> 13524 W, bo L,Wr5ei 00"Iy'a"( City-4,,,41A ZIP: a Ll 5 <br /> Email and/or Fax rie e- <br /> ARCHITECT/ENGINEER INFORM TIOtC <br /> Name: ct,.�50 L t� Dem6 <br /> Phone(day): (- q0 7-6o 5 c <br /> Address: 2 c!�„�,,, Cit : +f <br /> Email and/or Fax: p <br /> ,,`Flt'+o✓ v tic o d e K &IteutG t,c <br /> PROJECT INFORMATION: Description ofproject: ;,..t tol 1,,zk <br /> 1.Type of Project 2.Proposed Use 3.StAfeture Type 4. Sewage Disposal& <br /> ElNew Construction ElSingle Family with ElAccessory Bldg./Garage Water Supply <br /> ®'Addition attached garage ❑ Deck N/Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence ❑ Private Sewer <br /> Other:(specify) d° B ❑ Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑ ublic 4-feet or greater Public Water <br /> *`Any earth movement may also require j�Commercial ❑Storage <br /> MCWD review&permits. ❑ Industrial XWarehouse <br /> MCWD ❑ Private Well <br /> Minnehaha Creek Watershed District <br /> ! ) El (specify) Other(specify} <br /> 15320 Minnetonka Blvd Z <br /> Minnetonka,MN 55345 <br /> Phone: 952471-0590 <br /> Fax: 952471-0682 <br /> www.m innehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ i�j <br /> Last Updated: January 2015 <br />