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2;1 <br /> City of Orono tk_01.• <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: •�C/0- <br /> •� • PO Box 66 OK <br /> O O Crystal Bay,MN 55323-0066 Date received: /II– Z(-/ <br /> A 1Street Address:' `=� <br /> i}' Received by. 720 <br /> ti 2750 Kelley Parkwa 72 , J� If- 7Y7Cir) <br /> F' .�;l��• o L l (� Ian review fee: j <br /> LESHO�� Orono, MN 55356 I ( 44.0_________. <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 45C0 e.. .rovl r ,cd i-Q• ,3 <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: g2-S' Wil.-+-o\,.-1 Vi`yet ,e;\L <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 wilPPbe <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: \Moo Jcg f-r 0(:---4,14, &.>11.--o (NC:. <br /> State License# ilfa ciz,..S G92°{2(.‘ Expiration Date: 3-3 f-Z_,L7 1 3 <br /> Phone: (of 2--` c o-Ce41.<- (office) 1 t (cell) <br /> Mailing Address: 64,c City: /ar�,,,,,� ZIP: 5 �31�t3 <br /> Contact Person: (ZT �O}1 Applicant is: ontractor 1/ Homeowner <br /> i —, (Circle One) <br /> Email and/or Fax: R-`? wceor rdesk)a l'i l o C Den <br /> PROPERTY OWNER INFORMATION: <br /> Name: WENN IIVA16(. <br /> Phone (day): <br /> Address: 67r vii lA,1 JI 3IL1VE City: otLicy1 ZIP: <br /> Email and/or Fax <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 /> ID New ConstructionWater Supply <br /> ❑Single Family with 0Residence <br /> ❑Addition attached garage 0 Garage/Accessory Bldg. 0 Public Sewer <br /> ❑Accessory Building ❑ Single Family with 0 Deck <br /> ❑Relocationdetached garage 0 Office/Commercial <br /> n�I, ❑Private Sewer <br /> Other: (specify) F'L� 0 Multiple Family/Condo 0 Warehouse <br /> 0 Public 0 Storage ❑Public Water <br /> **Any earth movement may require ❑Commercial ❑Other(specify) <br /> MCWD review&permits. 0 Industrial 0 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.or. <br /> ' <br /> Estimated Construction Valuation (excluding land) Co7Cp <br /> Packet Last Updated: 03-06-2012 ..5 0°C) r , k r t, „, /� 2--I - <br /> I - 12 <br />