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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: <br /> (� PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> Al Street Address:' Received by: / �Pq <br /> D 2750 KelleyParkway S, 5S <br /> '�1 y Plan review fee: <br /> c` Orono, MN 55356 <br /> `1kf5Ho�� Main: 952-249-4600 Total Fee: `rio — d <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: C200 WILLOW 12?- SJy I d <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: go R- 50r1 IAC. <br /> State License# F2C too 11(n9 Expiration Date: 3 - 3 t <br /> Phone: cell CjSa -.7-97-- Eb30 (office) y5Z . -7(P7. TMIT <br /> Mailing Address: appC LAe L TS[rr City: \14A -141A ZIP: SS q I <br /> Contact Person: _ Fil ,, t n Applicant is: ontract / Homeowner (circle one) <br /> Email and/or Fax: 5�Ve . Cle,rt tOrl ) 14017- - 5o,t/- Cow► — <br /> PROPERTY OWNER INFORMATION: <br /> Name: L1 t La(?-A HAv l PAEV,(2-.� <br /> Phone(day): Lct Z - 201 - U'V(o <br /> Address: 3750 1-I0rNT1f-/&Tr 1J City:SrL,"5R99(L ZIP: 5SY((0 <br /> Email and/or Fax ✓✓IEU-4 . GnP'NkM 4MPgt-. CO--' <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: ,-jO/J 1pc_� <br /> Phone(day): (el? _ Z t i? - 15co <br /> Address: 700 Lw sr C_ City: vyMveM ZIP: SS 1 <br /> Email and/or Fax:wi fe.L1IllthVrl @ MQ2,`>W-) . CJS <br /> PROJECT INFORMATION: Descri tion ofproject: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> [�New Construction ElSingle Family with [Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence ( Private Sewer <br /> ❑Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> "Any earth movement may require ❑Commercial ❑Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse tJ Private Well <br /> Minnehaha Creek Watershed District(MCWD) Other:(specify) ❑Other(specify) <br /> 15320 Minnetonka Blvd ( dw5(.' <br /> Minnetonka,MN 55345 <br /> Phone: 952471-0590 <br /> Fax: 952471-0682 <br /> www.minnehahacreeLor <br /> Estimated Construction Valuation (excluding land) $ <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />