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City of Orono � <br /> Building Permit Application � ��� <br /> for New Structures or Additions <br /> Mailing Address: permit number: �`�J"'� �� <br /> ��A TO PO Box 66 — <br /> `V Crystal Bay, MN 55323-0066 Date received: �-� 5 �� � <br /> Sfreet Address:� Received by: <br /> 2750 Kelley Parkway '� ,5 <br /> �. � Plan review fee: � <br /> F c,` Orono, MN 55356 - <br /> �qkEs No��` Main: 952-259-4600 Total Fee: ��3 ��—� <br /> Fax: 952-249-4616 �,vvJvv G�i i�rnr�� �irr 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: � 7jq(,� �� , �� Qa,�`� �� <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 wifh Police Department and Ciry Council approval 60 days prior to the event. Shuttle bus service w�ll e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT I�NfF�QRMATION: <br /> Name: ���- <br /> State License# Expiration Date: <br /> Phone: (cell) (office) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF�O` RMATI�O : ` <br /> Name: /�l i vcz[1Q <br /> Phone(day): <br /> Address: 3 Cit : � ZIP: lj��� <br /> Email and/or Fax ,�; ��}-� �� ' �,� <br /> ARCHITECT/ENGINE�df�FORMATION: <br /> Name: �,(�. <br /> Phone (day): <br /> Address: City: ZI P: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of pro�ect: <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 /> [�ddition attached garage ❑ C�arage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ��eck <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&permits. ❑ Industriaf ❑ 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) � �, �� D <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />