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01/01./2011 12: 11PM 9524407310 VICKITERCERD PAGE 01/05 <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address. Permit number: Voll- b /Oto 3 <br /> Og,O�O PO Box 66 <br /> Crystal Bay, MN 55323-0066 a received: <br /> A a. StreetAddress:' ceived b . /� S <br /> 2750 Kelley Parkway P n review fee: <br /> moo$$ Orono, MN 55356 ' <br /> To I Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www i orono.mn.us <br /> This application form must be completed in full and all required iijormation must be submitted. <br /> Incomplete applications IIMA' as;tGENERAL INFORMATION: <br /> Job Site Address: VV YJ <br /> Will this be a Parade of Homes, Remodelers Showse HIr <br /> e or er Display Home? ❑ Yes L] No <br /> tf yes, a special event permit/s required with Police Department and Counprova/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient onsite parking is av able, Nermitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# o Expiration Date: -�313 /,2a I <br /> Phone: -,t, -Z Z Zoffice cell <br /> Mailing Address: _ city: ZIP-! 3-7 <br /> Contact Person: U I Applicant is: CZalftr Homeowner (clrcle one) <br /> Email and/or Fax: _ Cpy,7 <br /> PROPERTY OWNER INFORMATION: <br /> Name: Y-1 r7 L r� <br /> Phone (day): a � S S <br /> Address: _ /I e5 LVLf Pq 4 untie_ YVa City: L( � ZIP: 3-4 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 /> PROJECT INFORMATION: <br /> 7,Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal& <br /> I�New Construction ElSingle Family with ElResidence water Supply <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. ❑Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑Other. (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public kr Storage ❑ Public Water <br /> "Any earth movement may require ❑ Commercial Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Greek Watershed Dlstdct(MCWD) ❑ Other: (specify) <br /> 18202 Mlnnetonka Blvd <br /> Deephaven.MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> �mvw.minnehahacreek.orq <br /> Estimated Construction Valuatlon (excluding land) $ ':�3 ! 4 <br /> Laet Updated: 4/28/2011 <br /> - 19- <br />