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City of Orono
<br /> 1.
<br /> ` Building Permit Application _. L'
<br /> 1421i
<br /> for New Structures or Additions
<br /> Mailing Address: CRC,/,� -6 /50.0
<br /> �Q� I PO Box 66 EIVED Permit number: ,p
<br /> Crystal Bay, MN 55323=Q06�
<br /> RE Date received: 1 /l..
<br /> �� Street Address:' OCT 3 2016 Received by: /D —1.314'
<br /> 2750 KelleyParkwaypC 1 C/6 45-S))
<br /> -:;'.*4- l\1�� Plan review fee:
<br /> Orono, MN 55356 D!k _
<br /> kPSHOvMain: 952-249-4600 CITY OF ORONO Total Fee: l`�Q�
<br /> Fax: 952-249-4616 www.ci.orono.mn.us g"100 ex_ravd✓
<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) L; S l .),/Cpt-J t%i eA-i b r ,ve-
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? E 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: 66. r r%t,r (_a,.'(7/ C.kC-41
<br /> State License# 6c 63 g 2 U S Expiration Date: 3- .$ 1- /i7
<br /> Phone: (cell) [o 12 _3 6, G- 3 q (office) 76 3-55/6- //n o
<br /> Mailing Address: 7i0,-, ni a.ot f-li.p.— A vs( W. City:( ,,11h, V4-/ZIZIP: S's %27
<br /> Contact Person: J ,s ti L-4..",e,e, ,-. Applicant is: ontracto / Hofneowner( Circle One)
<br /> Email and/or Fax: --s7,5 k e. 6,-, ,--r-,_, ,-- -G,r-+s-/.r ,>t,L-- . c.-0-,---
<br /> PROPERTY
<br /> --
<br /> PROPERTY OWNER INFORMATION: f
<br /> Name: ce. I�.�,ccy
<br /> Phone (day): (o/2 -590 Siy i?
<br /> Address: /p( CA) ./c,v v :c�w
<br /> , 0 r?vti City: L
<br /> , S Lem.; /&/ ZIP:
<br /> ht,,,--)Email and/or Fax ht,,,--) . vet r��o nLa, . , c-ef,.,,.. in Q rhIl tafitq v)u,C,/on
<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 0 Single Family with 0 Accessory Bldg./Garage
<br /> ❑ Addition attached garage 0 Deck 0 Public Sewer
<br /> ❑ Accessory Building 0 Single Family with 0 Office/Commercial
<br /> 0 Relocation detached garage 0 Residence 0 Septic
<br /> ❑ Other: (specify) 0 Multiple Family/Condo 0 Retaining Wall(s) (Compliance certificate
<br /> ❑ 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 0 Public Water
<br /> Minnehaha Creek Watershed District(MCWD) 0 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 in nehahacreek.orq
<br /> Estimated Construction Valuation (excluding land) $ (p� Ot2X.
<br /> Packet Last Updated: January 2016
<br /> Page 21
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