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,. City of Orono <br /> I Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: 2615- /g <br /> PO Box 66 Permit number: J014 <br /> il-C1),41( <br /> Crystal Bay, MN 55323-0066Date received: — <br /> Street Address:' Receivedy ��t,='=�2750 Kelley Parkway Plan review fee: ► Ic.� <br /> Orono, MN 55356 o'�b1 Bbl��Q _ '— vise1KesH0¢t' Main: 952-249-4600 Total Fee: <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: 330 Le);„�3,4mme( 1,,c,.11-e...- <br /> Will <br /> c, t <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: K '. cLA- o'- Cos-4 C--k.--1-:,r, LC-c <br /> State License# (3C_OVS,: q Expiration Date: 3/_3j / )`7 <br /> Phone: (cellr 2) 911-- 32O (office) <br /> Mailing Address: 3�a,q Du,,„-1- Aut 5,5_,...q, Cit : A.•nn-e ;S ZIP:SS 489 <br /> Contact Person: I?\IA N ko(-der\ Applicant is: ontract•' / Homeowner (Circle One) <br /> Email and/or Fax: ✓' ..c"�Q, -2le-yo(,,,.Sn„cons...l-r,-,--V0,1. c_o„-I <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> in"- 54r�SlQr <br /> Phone (day): (6,17) 3o6- -'0S6 <br /> Address: S3 LA):-->djtA vvie. (.4ne, City: O(on o ZIP: Ss 361-( <br /> Email and/or Fax Mar-h .5--r-s5erg &lo, .coM <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: Ko.- A1xcL„cto.- <br /> Phone (day): C9Sn c(-43_g-4- 4 <br /> Address: L(o( £4s4- Lt- S-k City: 0.)czc,-�c ZIP: SS3`�( <br /> Email and/or Fax: (<c,kt,. ii 6? Ac:,,s xG,,,d o r c�S;5✓\ (-1/4-t.co J r--7 � �p <br /> PROJECT INFORMATION: Description of project: Pee VL Qdd if'i $ l Un4 S”1`T <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction Single Family with ❑Accessory Bldg. /Garage <br /> ,®'Addition attached garage ®Deck CV Public Sewer <br /> ❑Accessory Building ❑ Single Family with [IJ Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence <br /> ❑Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) ❑ Private Sewer <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> **Any earth movement may require 0 Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse sj Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ 641 an <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />