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City of Orono
<br /> Building Permit Application
<br /> for New Structures or Additions
<br /> A,
<br /> Mailing Address:
<br /> Box66Permit number: f 7-Q1579
<br /> �Of „, Crystal Bay, MN 55323-0066 Date received: �;?Q/-/7
<br /> Street Address:' Received by:
<br /> 4 2750 Kelley Parkway t-/-1...p5.35
<br /> 6t �` Orono, MN 55356 Plan review fee:
<br /> �'�xesxo�`� Main: 952-249-4600 Total Fee: /AO/7-0/57'ep
<br /> Fax: 952-249-4616 www.ci.orono.mn.us y(ip 4Id tha.en it/ e6cf-rx.321*Lar
<br /> This application form must be completed in full and all required information must be submitted. (J�)
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: /',9/ U�ti h'4't - 72 I 1
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? [' Yes ❑ 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/APPLICANTINFORMATION:,
<br /> Name: �tQA,\c k - t,id-o
<br /> State License# (3LZq•_,s,SCf Expiration Date: '5/ / /`
<br /> Phone: cell '75Z- 347 : . 1 * office Z S4Z-:90
<br /> Mailing Address: d72D E _ c (4t:,k / ,,,&- City: S.-els/el ZIP: ,A5.537
<br /> Contact Person: ) Applicant is: Contractor / Homeowner (circle one)
<br /> Email and/or Fax: -} NI. h l c3 ht Qhyvtlt/IC.C.OS. Co WI ; j i1'V1. fv1 (ii_,h/gh/YnG( -(1DS ,02)14,-1
<br /> PROPERTY OWNER INFORMATION (
<br /> Name: 10,--,--.. t��.14 1�T' U
<br /> Phone (day): (((Z - 7 - ,(S
<br /> Address: ! A ACit : revv.0 ZIP: _
<br /> Email and/or Fax , -t."- (-)'r'`a 5,A.Ae.,,
<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: ` ,
<br /> �`� e.s
<br /> Phone (day): ' -Z, a -- ), ,
<br /> Address: -.3-.K. l ,\-- am eft . City: &jlt,Su„ti, ZIP: 55. /7
<br /> Email and/or Fax: .j-a.i\1\-cf,, Q t+(-J;; ,Cc9v✓`
<br /> ARCHITECT/EN,CaINEE INFORMATIO/�:
<br /> Name: —,Kr.._ „/ .5A--),r. (49- )
<br /> Phone (day):
<br /> Address: ( 7 c.jljv\41' ( .1/...c- J0,Vk. City: ircyye„yk, ZIP: 554(4 (
<br /> Email and/or Fax: II-Wort,0\)(a ere t\i,,n5liVIDtA,fAAA , (o,N�
<br /> PROJECT INFORMATION: Description of project: 1
<br /> 1.Type of Project 2. Proposed Use 3. Str ture Type 4.Sewage Disposal&
<br /> Water Supply
<br /> ❑ New Construction 0 Single Family with ccessory Bldg./Garage
<br /> ❑Addition attached garage 0 Deck 0 Public Sewer
<br /> C7' 'ccessory Building 0 Single Family with 0 Office/Commercial
<br /> • -elocation detached garage 0 Residence 0 Septic
<br /> ❑ Other: (specify) 0 Multiple Family/Condo 0 Retaining Wall(s) (Compliance certificate
<br /> 0 Public 4-feet or greater may be required)
<br /> **Any earth movement may require 0 Commercial 0 Storage
<br /> MCWD review&permits. ❑ Industrial 0 Warehouse
<br /> ® 0 Public Water
<br /> Minnehaha Creek Watershed District(MCWD) OtFjer: (specify) ,_ ❑ Other(specify)
<br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 (a,�,.-�0).�, JJ 0 litartertIMED
<br /> Phone: 952-471-0590 / Fax: 952-471-0682
<br /> www.minnehahacreek.orq f
<br /> Estimated Construction Valuation (excluding land) $ 51D)o t ._., Li3I/
<br /> Packet Last Updated: January 2016
<br /> Page 21 CITY OF ORONO
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