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�. 5Se� <br /> � , �, . <br /> �IT�. t,�F OROI�Q o� o-� -�(P,.�J <br /> BUILDING PERIVIIT�APPLICATION � � � <br /> FOR NEW STRUCTU�tES OR�ADDITIQNS <br /> �O�O Mailing Address: permit�number: Q � -� 7a� <br /> PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: - D'� <br /> StreetAddress:' Received by: �L� <br /> �� `�'" 2750 Kelley Parkway Plan review fee: C�4� -�0�e� l <br /> t,y � � Orono, MN 55356 � � 138g,�.r � <br /> kFsxo � Total 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 information must be submitted. <br /> Incomplete applications wil(be e�eturned. (Please print) <br /> GENERAL INFORMATION: -1 � ` .' '� <br /> . Job Site Address: .�,d�� � ���+� c�e��, ��. <br /> Will this be a Parade of Homes, Remodelers Showcase r�e or other Displ y Home? ❑ Yes ❑ No <br /> If yes,a special event permit is required with Police Department and Citjr Council'approva/60 days prior to ty►e event.Shuttle bus service wlll be <br /> reguired unless applicent demonstretes sufficient on-site parking is a.vailable: Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: . <br /> Name: `�P`l�n I Cx�o1.S�r��,���e°t L°.e . <br /> �tate License# ��, � �-1, �' � Expiration Date: 3-�(- dLO Y(� � <br /> Phone: (cell) � `�- el�to P �3�'� (office) ��at- �2�- �$°i� <br /> �Vlailing Address: 3,g` ?"��e�� ��a So o �� � .�� L.�Qs P� Z�P� �5��� <br /> Contact Person: "7r'��� ��O(��'�ca- � Applicant is: ontractor / Homeowrner �cir�ie o�e� <br /> Email and/or Fau: '7'`��`T'C.� @, e.�a� �c�s-�Q A e�f' <br /> PROPERTY OWNER INFORMATION: " <br /> Name: ��-'�'��.��" �4,C�.� � L��� ���.� <br /> Phone(day): �1�- 'z�fZ - �4��53 <br /> Address: 2,2�r� �br����, �1�,,/ City: ��v�c� ZIP: ��3�� <br /> Email and/or Fax �y efi�k��� � h'��. �, �wti. <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: Ciiy: ZIP: <br /> Email and/or Fax: ' <br /> Pi�OJECT INFORMATION: Description of pro'ect: � <br /> 1.Type of Project 2.PrQposed Use '3.Structure Type •, 4.Sev+rage Disposal 8� <br /> � • ,. Water Supply <br /> ❑ New Construction �Sing�e Family writh �Residenee <br /> �4ddition attached garage'� � Garage/Accessory Bldg. ❑Public Sewer <br /> �]Accessory Building ❑ Single Famfly with �,Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Vdarehouse <br /> _____ __ ❑P�ab(i� � ❑Storage ❑ Public Water <br /> �„*� - ---- ❑ Ottrer(spec►fY) <br /> M� [�Private Well <br /> Mi <br /> 1�D - <br /> P <br /> F � THOMAS E.GULLIFER <br /> OFFICE: (9521 9Z - 40 _ <br /> � : (612) 490-6352 $ <br /> E �.�0.Oc�� <br /> TRIANGLE CONSTRUCTION INC. <br />