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a 0_4104 !oh7/, y <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions ��8- a S <br /> MailingAddress: <br /> 7,0,� PO Box 66 Pemtit number oZ0 —OC el JNI71- <br /> O Crystal Bay, MN 55323-0066 Date received: 5.- <br /> I�7 3 -, <br /> ;.\ 'Y r a, Street Address:' Received by: ► ` <br /> Is ''''41A. ti 2750 Kelley Parkway Plan review fee: <br /> Z rsr �o Orono, MN 55356 C2 0 / _ 7 <br /> Hoo 60 <br /> Total Fee: j <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. 2.60o 13S� <br /> Incomplete applications will be returned. (Please print) ttii�� <br /> GENERAL INFORMATION: � 20(L'00`� <br /> Job Site Address: 95o 1�t t\R W V i-2�) 1brlve� Of0n0 �� ���5 <br /> , <br /> La <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? E Yes tic 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: A ty ssc. KoAxve,, <br /> State License# Expiration Date: <br /> Phone: q57.- 4 2 - q 07C_ . _. . a r-, ',, , i (cell) <br /> Mailing Address: c0 U 11Quu Ui23,,3 ur -ZI ,, 2 ZIP: 553 rj(o <br /> Contact Person: Aly& KO,Y�U.p, 3 l-7 ne (Circle One) <br /> Email and/or Fax: G. Kam iv-e ea m 01 11 I„jdr,,,,a f2rta if( a -K1 / <br /> PROPERTY OWNER INFORMATION: <br /> Name: �VL! Un3/u0`� <br /> 'SL -\r C018 (31\\11, <br /> Phone (day): 92-4 Z(1-LI 0-7 0 CC <br /> Address: q 5a ( i 1kow U 1 Dr ZIP: 5 rj 5 l0 <br /> Email and/or Fax Ok.KO"'t\P 0 me hS ` <br /> ARCHITECT/ENGINEER INFORMATION; Jh I l Irtouv9- 4125-"`' <br /> Name: t'S-V 1T1, ZW Oar-1- 01 s q� I�,�' ,n/�/ �y� ��-� <br /> Phone (day): Ct1 Z-�O -FUU 4 l�al.� Vy fj �.�✓ir�' ' � <br /> Address: 13Q t CU `{ SL ZIP: 65 33`i <br /> Email and/or Fax: {Sevin Q Sport ‘41— CNA iy,, �L�J u�, v <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Propos__ ___ -_ Sewage Disposal & <br /> Water Supply <br /> ❑ New Construction El Single Family with 0 Residence <br /> ❑Addition attached garage 0 Garage/Accessory Bldg. Public Sewer <br /> ❑Accessory Building 0 Single Family with 0 Deck <br /> 0 Relocation detached garage 0 Office/Commercial 0 Private Sewer <br /> sz Other: (specify) pori' Court- 0 Multiple Family/Condo 0 Warehouse <br /> 0 Public 0 Storage X Public Water <br /> ""Any earth movement may require 0 Commercial M Other(specify) <br /> MCWD review&permits. 0 IndustrialSport- GAur4- 0 Private Well <br /> Minnehaha Creek Watershed District(MCWD) Other: (specify) <br /> 18202 Minnetonka Blvd ,r,*. CD u - <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minneha hacreek.orq <br /> Estimated Construction Valuation (excluding land) $ 1 (0)000 <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />