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l <br /> ..._ <br /> City of Orono -� �' \\\klio <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: 0-61075- <br /> 0"3.4V) <br /> PO Box 66Crystal Bay, MN 55323-0066 Date received: 8 c9, /0 <br /> ,., .;V.,. � �, Street Address:' Received by: 7)4, <br /> ��c, y � �1"�+ G�ti 2750 Kelley Parkway Plan review fee: <br /> ..t 0,11".,p <br /> Orono, MN 55356 !!� <br /> Main: 952-249-4600 <br /> Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: '4 9.// P <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 /I l - <br /> Job Site Address: C7 5, `0 4 rj �, >° t) �f-, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [ b <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/APP ICA T INFORMATION: <br /> Name: irro� /cc. -e-,ir-P Cc. <br /> State License# , It _ p? 7 Expiration Date: / ,7766 z <br /> Phone: t�'�- 1 gg= e (office) „.,„....-_e____ (cell) <br /> Mailing Address: /'gam ,(�yy��,,.,„," 4,.. 5 - 9 Cit : £a. , ,,,- ZIP: \3175'L,2� <br /> C•. act Person: ♦Gt ve__ /Vci- Applicant i- ontra 'or Homeowner (Circle One) <br /> 411M and/or Fax: . % ,le-e 5 .ter;5 -...' 5en2e ? - . 6jvi <br /> PROPERTY OWNER INFORMATION: <br /> Name: Lou -94 /liar, E-- L/c.5 <br /> Phone (day): 4 / --'7/8/-- . 4 <br /> A s: 1 a5' 4),//o,J e-k) Or-. City: ( /0,-2_ p ZIP: 57.5--,3 377 <br /> Email nd/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 /> Water Supply <br /> ❑ New Construction ngle Family with Residence <br /> E Addition attached garage ❑ Garage/Accessory Bldg. ublic Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation Ledetached garage ❑ Office/Commercial Private Sewer <br /> \� Other: (specify) 4.60�C3e41 /J� ❑ Multiple Family/Condo ❑Warehouse <br /> � L El Public ❑ Storage CV(1Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. El Industrial <br /> ❑ 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) $ 07"/ D eY-o--. c)-6 <br /> Last Updated: 9/29/2009 <br /> - 17- <br />