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City of Orono �t <br /> Building Permit Application , , s ,i/. <br /> 72,_.) <br /> for New Structures or Additions <br /> Mailing Address: Permit number: o?O/( --a7/.5 <br /> WA, PO Box 66 <br /> j v0 Crystal Bay, MN 55323-0066 Date received: —, 7/--/k <br /> Street Address:' Received by: �'/ <br /> '' 2750 Kelley Parkway <br /> 6� Plan review fee: ��(o— <br /> 01 Orono, MN 55356 <br /> e'1kFsrtos-- Main: 952-249-4600 /fo -d// 5-7 <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: I Pc i ii l l ov) b Cooh Dr tue <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes j 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/APP ANT INFORMATION: <br /> Name: f QC (t)t` }fUC: I- L <br /> State License# 1 L 70,„?..Sy , _ C Expiration Date: 313) /o17 <br /> Phone: (cell) 8 (office) <br /> Mailing Address: 510 •rlr • _nue 6 . = ; ZIP: 553).V <br /> Contact Person: Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: pec O"s c i. . ‘ , (pr.- <br /> 1/4T <br /> PROPERTY OWNER INFOR ATI ! G.L�/ <br /> Name: /��j%%" . ----i /( ��{Z <br /> Phone (day): G i'2- ZS—Z> cv3Cc <br /> Address: //73-- w,// by •€ City: Q,Pryro ZIP: S�3"/ <br /> Email and/or Fax ,,,,, Com'pr,,..-c1�/,7.,�.„,-_c <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: •;,r\ /� <br /> Phone (day): - '10-- <br /> , V <br /> �p. <br /> Address: Dp 0 r• ' e j City: i'se ZIP: c53'- <br /> Email and/or Fax: eu,' r\-%/le k2 uMt (', WA- <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: / <br /> PROJECT INFORMATION: Description of project: , ;J(}-.'-z C . <br /> 1.Type of Project 2. Proposed Use 3. Structure Tyfoe 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction 0 Single Family with Accessory Bldg./Garage <br /> 0 Addition • attached garage Deck 0 Public Sewer <br /> Accessory Building 0 Single Family with 0 Office/Commercial <br /> 0 Relocation detached garage 0 Residence SiSeptic <br /> ❑ Other: (specify) 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 ❑ Commercial 0 Storage <br /> MCWD review&permits. 0 Industrial 0 Warehouse <br /> 0 Public Water <br /> Minnehaha Creek Watershed District(MCWD) Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd; Minnetonka,MN 55345 (�ria�`C '' rivate Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ $60 000- <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />