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iL , 54(-) <br /> City of Orono <br /> Building Permit Application ;, 0 1 v j! ,i--(� <br /> for New Structures or Additions <br /> V CIO <br /> Mailing Address: <br /> Permit number <br /> g,� � PO Box 66 —00..;: t4 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a, 4. Street Address:' C <br /> Received by: -{) /c.0 <br /> �� ) o~ 2750 Kelley Parkway s ( .2 Plan review fee: (L,�' : �- <br /> ��`�xEssot• <br /> + Orono, MN 55356 <br /> Total Fee: <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: <br /> Job Site Address: /-2 /,./ .1 72 - , <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? D 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/APPLICAN INFORMATION: <br /> Name: _ Tf ' <br /> State License# iration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� tom." /77. / le, <br /> Phone (day): 3-a4D -,.-k_Jr - 1/4, <br /> Address: /�2 9 > Lz..//%,/Aa-,-.(- 7,-/ City: ..,)ry,v ZIP: -4 IV- 4 %y <br /> Email and/or Fax AiI A_ FiV/ - 3716 3� T-V' '7 <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: �/ <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 gSingle Family with /aResidence <br /> ❑Addition attached garage 0 Garage/Accessory Bldg. 0 Public Sewer <br /> ❑Accessory Building 0 Single Family with 0 Deck <br /> ❑ Relocation detached garage 0 Office/Commercial 0 Private Sewer <br /> N Other:(specify) remove_ Q x'44;q3 0 Multiple Family/Condo 0 Warehouse <br /> anc(ockt pc,r-cIA_ 'u-,d re p 1w c... 0 Public 0 Storage 0 Public Water <br /> "Any earth movement may require lJ° 0 CommercialOther(specify) <br /> MCWD review&permits. rd�� Industrial �C 7C ,.)c-.-_A <br /> � Private Well <br /> Minnehaha Creek Watershed District(MCWD) they:(specify) <br /> 18202 Minnetonka Blvd 74u.,c k c.� /e i-, <br /> Deephaven, MN 55391 �`_� <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ _L j ,,, (-)c,.. <br /> Last Updated: 4/26/2011 <br /> - 19 - <br />