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i <br /> CITY OF ORONO <br /> BUILDING PERMIT APPLICATION 4,r7 4 .4P <br /> FOR NEW STRUCTURES OR ADDITIONS <br /> �0. Mailing Address: Permit number: 020/7 — 0/1/1012 <br /> PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ��8 7 <br /> Street Address: Received by: ,(4 0201,z-12/5159 <br /> S G` 2750 Kelley Parkway Plan1re_view ee: �/ �S 7/ 3V <br /> t Orono, MN 553560 / _ , f <br /> -kES Hove4:77e---5—°°' <br /> otal Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 070 /7-e/s/ <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: CO fp Pothei/SJ C t'cfi <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? n 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: /l/dc--on f-fvi-cS, t I_ L <br /> State License# 6L (o 59??-1 Expiration Date: 3-3/"/9 <br /> Phone: (cell) (04,M-7 4,421 (office) 71,3.555 .99/ <br /> Mailing Address: ,*..it $44, i . hJ • 0 Cit : ' ji d V ZIP: S5yy , <br /> Contact Person: r" Applicant is: . rac or / Homeowner (circle One) <br /> Email and/or Fax: ch r, n or-h7n horn eS, Gam, /9YYL9 U1 ' orYzhJr/Grn>PS .C -, <br /> PROPERTY OWNER INFORMATION: <br /> Name: joulrc., bread eve/4m ct <br /> Phone (day): 91'355/-dieD <br /> Address: / -,..1,5 (1$'",94e N. 5* . D City: /*m(.vf1) ZIP: 5-5-W6 <br /> Email and/or Fax rut1.1 11, /and. ['o,.,.. <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: &rvc L-e re,— <br /> Phone (day): 71 3• S3 s• ,9-7 KG <br /> Address: 90 S' t a. /hit. N City: Cy&71 ZIP: Ssya"-] <br /> Email and/or Fax: c�}')'lO1GL�Q.�lot� Loy,. <br /> PROJECT INFORMATION: Description of project: / j ) ( S/a _ Ca7S. /ci'c ) <br /> 1. Tye of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> New Construction lingle Family with lE<Residence <br /> ❑ Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑ Accessory Building ❑ Single Family with ❑ Deck �� <br /> ❑ Relocation detached garage ❑ Office/Commercial Lt Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may also require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial 1211<ivate Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> $ tf'60/ , <br /> Estimated Construction Valuation (excluding land) S UUv <br />