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064' 1005 <br /> .. <br /> City of Orono <br /> BuildingPermit Applicatio ' 2/• 7 S <br /> r <br /> for New Structures or Additions <br /> Mailing Address: Permit number: pZ 0 I`f--00 30 <br /> QA, PO Box 66 / <br /> *ese <br /> Crystal Bay, MN 55323-0066 Date received: -QQ2�j- <br /> Street Address:' Received by: V <br /> y 2750 Kelley Parkway cic <br /> Plan review fee: ti / 27 I I . �� pi <br /> Orono, MN 55356 LI-- <br /> / `a�'�kESHOl" Main: 952-259-4600 Total Fee: OO I LI ^0034: <br /> 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) a1AVN rteCOC <br /> GENERAL INFORMATION: /, <br /> Job Site Address: LGA W !t-94ugST Tg.L— , 0koj0, M,.) CCf6,G <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes M 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 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: ASiM /VW T f O(.> <br /> State License# Expiration Date: <br /> Phone: (cell) 6 I Z - 143 2 - GO 9) 6 (office) <br /> Mailing Address: O_t,I LifLDNVAS r Tf - City: ORO )0 ZIP: 553611 <br /> Contact Person: Applicant is: Contractor / (Homeowner" (Circle One) <br /> Email and/or Fax: C �4 Yne je 478@ ya4eo - cowl `—'--� <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: LI�CS T yI, Dion, .06.94AJ <br /> Phone (day): $8 8 W - 31131 -- <br /> Address: PO / o X Zj f J"14 City: woo Dr UfaL y ZIP: 5--S-7 ZJ <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal & <br /> Water Supply <br /> g New Construction N,Single Family with Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. N Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private 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. ❑ Industrial cg,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) $ - 0O0 <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />