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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: ` <br /> Q A T PO Box 66 Permit number: =LC'77- CC (// <br /> iiLj w� Crystal Bay, MN 55323-01../ Date received: 'f — -2<, _/ -) <br /> Street Address:' l 1 I Received by: 7C/' <br /> 2750 Kelley Parkway 11 <br /> 1.0sC' Orono, MN 55356 Plan review fee: -v(c (-)- c%1: . C <br /> �4krSHOI'v Main: 952-249-4600 Total Fee: Pl. • <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: I f <br /> Job Site Address: g s 1 S W 1)l V ti p p . <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ,rEC 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 INFORMATIQN: k � <br /> Name: L k- C-a.,•v 0.,n <br /> State License# 6C ct(0 7/ Expiration Date: 3, '7 <br /> Phone: cell (,)(L. 2 I I D office `I S Z, Y- J <br /> MailingAddress: 2 ;�l _ - <br /> _ �-' S � ZIP: 7 <br /> Contact Person: Applicant is: C• racto / Homeowner (Circle One) <br /> Email and/or Fax: ! A-t , , t n.4. tilPciv(N I'V t-0.,.-,, <br /> PROPERTY OWNER INFORMATION: <br /> Name: Corcl - it-,-11‘11 (e-_;'( it, et- kJ <br /> Phone (day): (c t 2 2 1O ' 7 <br /> Address: t r I r we) v$/ PL . City:PO A rI/e ��,1 ZIP: cc3 S 1 <br /> Email and/or Fax <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 <br /> Single Family with 0 Accessory Bldg./Garage <br /> ❑Addition attached garage 0 Deck <br /> SI Public Sewer Accessory Building 0 Single Familywith 0 Office/Commercial <br /> ❑ Relocation }- detached garage ® Residence 0 Septic <br /> p Other:(specify) L1. I--e rt 11'i Ai 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 0 Commercial 0 Storage <br /> MCWD review&permits. 0 Industrial 0 Warehouse <br /> Public Water <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 <br /> 0 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ �5l a 0 o <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />