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City of Orono <br /> Building Permit Application <br /> for New Structures orkAdditions <br /> Mailing Address: Y' <br /> �Q A> PO Box 66 �� Permit number: CAW-. !I <br /> `VQ Crystal Bay, MN 55323-0066 I J Date received: 9-013-46 <br /> � pr Street Address:' r 1 J Received by: �-r 'yF <br /> yy �j O5 I 5.Jeee: ✓ <br /> e4kESHO' Main: 952-249-4600Total Fee: 010/(P-0//7 6 <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) <br /> GENERAL INFORMATION: <br /> Job Site Address: Sita5 (J, (foy„( tf•t.A...1 'r- pr r1 0 , NF{ a '3Sty <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/APPLICANT INFORMATION: <br /> Name: kw.- Construction Illc,_ <br /> State License# .B C.IS2ftoZ Expiration Date: 3 i3h.I g <br /> Phone: (cell) (office) <br /> Mailing Address: gss wa za1a avd W City: WG'La}4., ZIP:55391 <br /> Contact Person: Applicant is: Contractor / omeowner circle one) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: b_vr 4. &kr ,t Co <br /> Phone (day): Gt2 7Gt <br /> Address: 1,4;11E5.04 trees..t Or City: Or tj ZIP: 15655—rte <br /> Email and/or Fax viri, argviy CP. -17 : cty! <br /> bb <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: 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: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction X Single Family with 0 Accessory Bldg./Garage <br /> ❑Addition() <br /> attached garage 'Deck 'Public Sewer <br /> 0 Septic <br /> ❑Accessory Building 0 Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage 0 Residence <br /> Other: (specify) Leck e 1 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. 0 Industrial 0 Warehouse ("Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 0 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ SDI 000.00 <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />