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} CITY OF ORONO <br /> BUILDING PERMIT APPLICATION <br /> FOR NEW STRUCTURES OR ADDITIONS <br /> �O A TO Mailing Address: Permit number: aZ/7 4/5 / <br /> V PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: `,l-5—17 <br /> Street Address:' Received by: <br /> G� 2750 Kelley Parkway Plan review fee: 3 D <br /> SHC4� Orono, MN 55356 OZ D 7 7 <br /> Main: 952-249-4600 Tot�F��� <br /> Fax: 952-249-4616 www.ci.orono.mn.us L,- AP 7--0/ <br /> This application form must be completed in full and all required information must be submitted. <br /> GENERAL INFORMATION: Incomplete applications will be returned. (Please print) <br /> Job Site Address: I ( 0 UJ'A; e-C,vr, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes SNo <br /> /f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service w� 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: 1�' <br /> State License# Expiration Date: <br /> Phone: (cell) (office) <br /> Mailing Address: (c-) fZ0 City;— �17�s� ZIP: S" R <br /> Contact Person: A,��D2 7A C oej3 Applicant is: Contractor Homeowner (Circle One) <br /> Email and/or Fax: .Aj,-C> <br /> PROPERTY OWNER INFORMATION: <br /> Name: i V\Q 10 :-►.,�- ` (1 GJ� r <br /> Phone (day): L5 i - <br /> Address: k t ;L1.S to 11-�U,{ O <br /> Email and/or Fax T)A\)„o.A&AGrvL-rl M C c t`► �' <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: _a3Sa. City: CJ1NS-T`z.0 ZIP: <br /> Email and/or Fax: 7 2.sz-1C-sv e, <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4. Sewage Disposal & <br /> New Construction Single Family with [1Accessory Bldg./Garage Water Supply <br /> ❑ Addition attached garage ❑ Deck <br /> ❑Accessory Building El Public Sewer <br /> 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 also require ❑ Commercial ❑Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other:(specify) <br /> 15320 Minnetonka Blvd ( p �) Other(Specify) <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Estimated Construction Valuation (excluding land) $ -3a DO C) <br /> Last Updated: January 2015 <br />