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C y Oron <br /> Buildi Per it lic i <br /> for New ructures or Additions <br /> Mailing A Permit number: o��//- �a�5� <br /> O.¢,�,�.0 ox 66 <br /> Crystal Bay, MN 55323-0066 Date received: � a 7 // <br /> ,� ���� Received by: <br /> � �, StreetAddress:' <br /> '�,�, �'j Gti 2750 Kelley Parkway Plan review fee: <br /> ' , i: <br /> l� � ������ Orono, MN 55356 �� <br /> 9kESH�¢ ao��-000 o � <br /> --� Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us � ��9 <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: f �L �i�� �`�>�G;✓el� ��''�l� r� �`� �S�� .�-� � <br /> � � <br /> Will this be a Parade of Homes, Remodel s Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wil/be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFO�MATION: <br /> Name: ���`'V� ����%�C �S . - , �- � <br /> State License# Expiration Date: <br /> Phone: %�(2 ts'ZS(c%(�Olf (office) (,�/2 72 3>�(0 (cell) <br /> Mailing Address 3 - _ , Cit : � r, r�c ��i, ZIP: �� �� ��' <br /> Contact Person: . ' Applicant is: Contractor / Homeowner �c�.�ie o�e> <br /> Email and/or Fax: ' ,r�� . L, C' � � � �''y27CGi�-LU✓�1 <br /> ' �,�/ �- ��'Y �c ,� � � � � <br /> PROPERTY UWNER INFORMATION: L�' <br /> Name: 77u��/��.� ✓� �� j'�C v'�. C c..� S <br /> �--T. �, � �- <br /> Phone (day): � `��( 3 ' ,.,�; <br /> Address: - ��S � Cit : rV1 i vl CCi ) � ZIP: .`���-��� (�' / <br /> Email and/or Fax . L - l C 'S "' �r � <br /> �: <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: � � , J � �� �U <br /> Phone (day): (�2 '� G �- �7 Ct/� � , � <br /> Address: �� `5/� (J�l�n� (� � city. 1�1�nn��.,�-/� � ZIP: _`>;�/C� <br /> Email and/or Fax: ���,'1��r���-,slcr C� IY�Sri-Cc�%'ti" <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ,�Residence <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 ❑ Storage ❑ Public Water <br /> "`"Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�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.or <br /> Estimated Construction Valuation (excluding land) $ � C'�J <br /> Last Updated: 12/21/2010 <br /> - 19- <br />