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�O 53 <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions 7040.16 <br /> 0 MailingO Bdodrss6s: Permit number: jo/O -40195 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> a y Street Address:' <br /> Received by: �yS <br /> 2750 Kelley Parkway Plan review fee: ���3 ,/q <br /> kEsso� o/D OD/ <br /> Total Fee: <br /> Main: 952-249-4600 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: S Npr-'-., Fv-nd dd.. <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: Lot Evos, apvylpc <br /> State License# a,0 a ss SS Expiration Date: 3....a1- (t <br /> Phone: C(S'a — cR4'4—ggqq (office) (cell) <br /> Mailing Address: 1501 a 1..twv —f City: t oka ZIP: S534S <br /> Contact Person: 0etil NrN 5 L..rLvl dyy1Gt'.i .L Applicant is: ontractor / Homeowner <br /> (Circle One) <br /> Email and/or Fax: S3-014a-1068 <br /> PROPERTY OWNER INFORMATION: <br /> Name: Car stn. t, Kacrr~o inn Glo.d- <br /> Phone (day): "1 b3- a a l- 4 1 4 id <br /> Address: (795' fJ --In Fe.;t' wAr p City:()0Lyzo ZIP: S$3q <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: Le.y Bros 4-0 y <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal & <br /> Water Supply <br /> El New Construction X.Single Family with igt Residence <br /> ❑Addition attached garage ❑ Garage/Accessory <br /> El Accessory Building CI Single Family with ❑ DeckBldg. Public Sewer <br /> ❑ <br /> ❑ Relocation L n detached garage ❑ Office/Commercial <br /> ®,Other: (specify) `CrtOr Rene d;❑ Multiple Family/Condo El Private Sewer <br /> e,�(�� P y ❑Warehouse <br /> **Any earth madement ire u� ir�ie -) ❑ Public ❑ Storage ❑ Public Water <br /> may q ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private 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 /> Estimated Construction Valuation (excluding land) $ l5O)00o <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />