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City of Orono <br /> . + Building Permit Application <br /> for New Structures or Additions <br /> MailiPO Bo�r66 � Permit number: 2O I ��-��C;�jt(Z <br /> �O`VD Crystal Bay, MN 55323-0066 Date received: --j c'j <br /> Street Address:� Received by: � <br /> y ,� 2750 Kelley Parkway �� ( G Plan review fee: G'" <br /> �' �` Orono, MN 55356 5`�J��J <br /> l�kESH��� Main: 952-249-4600 Total Fee: <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 applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �O� (�c�y S io�-� �v�.c I <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f yes,a specia/event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e bus service wi/I be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPL ICANT INFORMATION: <br /> Name: (r���Y�i ��^'��S <br /> State License# ��.S`f Expiration Date: <br /> Phone: cell (;t� —� �{ -- °[p� office <br /> Mailing Address: : �'� � �� r��� Cit : � U� .e ZIP: <br /> Contact Person: � l.�v� Applicant is: Contractor / Ho eowner (Circle One) <br /> Email and/or Fax: ��1�a��_G o�4�o� �v�.�e� ,c o w, <br /> PROPERTY OWNER INFOF�MATION: <br /> Name: (to ►���c� <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type o-Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> ew Construction ngle Family with ❑Accessory Bldg./Garage <br /> ❑ Addition attached garage ❑ Deck ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence �-Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> `*Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse ivate Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ���� (��� <br /> Packet Last Updated: January 2015 <br /> Page 20 <br />