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City of Orono <br /> Building Permit Application 7,Vg, g/ <br /> for New Structures or Additions <br /> Mailing Address: <br /> 0.1 <br /> VPO Box 66 Permit number: o?4l7—Q/lo 2) <br /> ek Q Crystal Bay, MN 55323-0066 Date received: /02 / / <br /> Street Address:' Received by: � <br /> y� g ,�• 2750 Kelley Parkway y.,,d64: I41:.Plan review fee: /P y /, 7 <br /> & Orono, MN 55356 <br /> "lxfsHo'� Main: 952-249-4600 I iTotal Fee: 020/7-0/10.2R <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 application will be returned. (Pleas int) <br /> GENERAL INFORMATION: <br /> 0 <br /> Job Site Address: -, 3 es ; ,, e- .. <br /> Will this be a Parade of Homes, Remodelers Sho - Home or other Display Home? ❑ Yes 11] No <br /> If yes, a special event permit is required with Police Department and• i ouncil 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 no.e allowed. <br /> CONTRACTOR/APIP T INFORMAT I <br /> IL, <br /> Name: ; jl <br /> State License # piratio ate: <br /> Phone: cell office <br /> Mailing Address: `j /11111VI'.Nl4r T ,�,,,'J L , ZIP: • .... <br /> •� <br /> Contact Person: <br /> Applicant is: Contrac�.r / Homeowner (circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNORMATIO) • <br /> Name: i . , /..0„. � o, <br /> Phone (day): Al • i /i/a �r-+�3'�` <br /> Address: ' ei City: ZIP: <br /> Email and/or Fax 7 i', _ t�J [�� t'tc ,P (� - it ` <br /> p' -Tit <br /> ARC - EC / ENGIN ER INFORMATION: <br /> Na _: r .- . II Jaddie <br /> , <br /> All <br /> Phone (day): i _ i`nfger, /- % % � / <br /> ,� 1, <br /> i1 „r. <br /> Address: ./ ��,`1%.�” - <br /> _. - _ Cit : ZIP: <br /> Email and/or Fax: <br /> ARCHITECT ENGINE R INFORMATIO <br /> Name: i .- :c ^ <br /> I/,�i <br /> Phone (day): R -r 0-9 0. <br /> Address: '�1PIM' Mt�� ,r %�e Cit : 1, , ZIP: — /� <br /> Email and/or Fax: 1 <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Construction ❑ Single FamilywithWater Supply <br /> ❑Addition g ❑ Accessory Bldg./Garage <br /> attached garage ❑ Deck <br /> ❑Accessory Building 0 Single Family with 0 Office/Commercial ❑ Public Sewer <br /> ❑ Relocation detached garage ❑ Residence <br /> CI Septic Other:(specify) ❑ Multiple Family/Condo0Retaining Wall(s) <br /> (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> **Any earth movement may require 0 Commercial ❑ Storage <br /> MCWD review& permits. ❑ Industrial 0 Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka, MN 55345 <br /> Phone: 952-471-0590 / Fax: 952-471-0682 El Private Well <br /> www.minnehahacreek.orc ,„ <br /> Estimated Construction Valuation (excluding land) $ 5jL J e'/ ki ` 77 <br /> Packet Last Updated: January 2016 l.f j // <br /> Page 21 <br />