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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> _O Mailing Address: Permit number: c D/0-A OQ C) <br /> PO Box 66 <br /> 0 Crystal Bay, MN 55323-0066 Date received: 9-7-/0 <br /> A,*,^(r ' Street Address:' Received by: `�A <br /> �� '�� ' �' 2750 KelleyParkway -- <br /> . . ,- Orono, MN55356 Plan review fee: I?D e LOI�eG�fC�(f� L� <br /> �Esxo4`' <br /> Total Fee: I5I 03 <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: /1'30 Wi I10-y./ S, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [ZI 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: <br /> State License # OtoN Expiration 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: $4-(4,1- gOr•✓M AD/ <br /> Phone (day): Cott- 2_ E- (m3 .9 <br /> Address: g212- cieiv, PL- City: 04, hass-e4A ZIP: X31../ <br /> Email and/or Fax e,6enninna.4. ^ tin G h5; - Ccrivx <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 ❑ Single Family with El Residence <br /> l'Addition (bt_c k) attached garage ❑ Garage/Accessory Bldg. E 1'Public Sewer <br /> El Accessory Building [}Single Family with Ijill5eck <br /> El Relocation detachedara e <br /> ❑ Other: (specify) g g ❑ Office/Commercial El Private Sewer <br /> ❑ Multiple Fq.mily/Condo El Warehouse <br /> ❑ Public El Storage ❑ Public Water <br /> **Any earth movement may require ❑ Comme ial El Other(specify) ,�� <br /> MCWD review&permits. ❑ Industrial LK 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) $ 3 OM , 00 <br /> 1 <br /> Last Updated: 9/29/2009 <br /> - 17- <br /> i <br />