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To: permit desk Page 2 of 7 2015-06-23 18:48:19(GM'T) 15072999410 From:AMANDA BINSTOCK <br /> � , CiTY OF ORC�NO <br /> � �UILDINC PERNIIT APPLICATI(�N � <br /> FOR fVEW ST�UCTURES OR ADDITi�NS a <br /> M2fllrlgA9d�s5: � . Permit numher: �`_ — v8� <br /> ��T� PO Box fi6 <br /> , Crystal Bay,MN 55323-U06 I�y Date recefved: �/Z <br /> Street.address: �I�'� Receivea by: <br /> � �4� 2750 Kelley Parkway Plan revi�wl�e; <br /> � Orana, MN 55356 /_ <br /> f�kESH�4� 70ta)�8@; Q�,�Orj�(o <br /> Main: 952-249-4600 Fax: 952-249-4616 �_ci.orono.mn.us <br /> This appllcadon form must be compieted in fult and a�l requlred irtformation m�t b�s Itted.�� <br /> Incornplet�app�(cations will be returned. Please prrnt <br /> GENERAL INFORMQTION: a - __a <br /> Job Site Address. �'�,�'] � j�-y�'}p�' ''�*��- <br /> Will this be a Parade of Homes, Remadelers Showcase Home or other Display Home? ❑ Yes �Na <br /> X yes,a specief everrt pemtit Is�equ�red w�tt Poike L1ap�rL�rrorH artd G'tty Coltnct!approva!60 days prior to the ever�. Shcdtde hus servJCe wiH be <br /> ,�equirsci unJess appHcant dema�strates sufJ7�nt arr-s#�parking is�vallable. Adon-pet»ihtCd BVB»t3 vdlN nOt be BdOt�d. <br /> CONTR�ICTOR 1 APPUCANT INFQRMAT{dN: <br /> � �. <br /> Name: /1 - � � � - <br /> �-..._.__... _.__ _ . <br /> State License# �(';f ` '72__ Expiratian Date: �� j�� <br /> Phone; oel offiae - $7' b �3� <br /> Mailing Address_ +-}GC s� Ci _ ZIP. 1�+0�:� <br /> Contact Person: � Applicant Is: �entra�to Homeowner ic+re�a�� <br /> Email and/or Fax: �,�pti�5����.,{�i,i <br /> _' <br /> PRBPERTY t3Ww INFORMA O : <br /> Name: f� C, Y � <br /> Phone(c3ay): •2�� <br /> Address: Ci ;y�, - ZIP: �r�� <br /> Emaii and/or Fax <br /> ARCHlTECT J ENGINEER INFQRMATION: <br /> hlame; <br /> Phone(day): � <br /> Address: City; ZIP: <br /> Email andfor Fax: <br /> PROJECT INFORMATION: Descri tion of ro'ect: ��ti`Id Y ��,�a1 � C� 1(YIGi� s�'' <br /> , 1.Type oE Praject 2,Prnpossd Uss 3.Struckune Ty 4.Sewage Dispa�� 8� <br /> � Water Supply i �� <br /> I <br /> ❑New Gonstruction []Singl�Family with ❑Res�dence <br /> ❑Addition attached garage ❑Garage/Accessory Bidg. ❑ Fub�ic Sewer <br /> ❑Accessay Buflding ❑ Single Farruly wfth ❑aeek <br /> ❑ ReloC�tion d�teched g�rage ❑QfficetCommercial ❑ Privaie Sewer <br /> ❑Other. (speclty} ❑ Multipie Family/Condo ❑Warehouse <br /> ❑ Public ❑Storage ❑ Public V�Jater <br /> •*Any earth movement rnaq aiso require ❑Commerciai ❑t]ther(specifyj <br /> MCWD review 8 permits. ❑ Industrial ❑Private Wel! <br /> MinneYraha C�eek V'Jat�rshed DisVict(MC1MD) ❑�her. (specliy) <br /> 18202 f�nnetonka Bivd <br /> Deephaven,MN 55391 <br /> i Phona: 952-471-0680 <br /> Fax: 952-377-0682 <br /> www.min h h r k. <br /> Esifmated Construction Valuation(excluding I�nd) $ ��`1� <br />