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� City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: o70/O-DU�"��' <br /> �v�,� PO Box 66 Permit number: <br /> �Q F\ Q Crystal Bay, MN 55323-0066 Date received: 1�'��'�0 <br /> � ��`� i Received by: '�?/f <br /> ��� ,���'������� �, � StreetAddress:� <br /> ��'�n �h��'�.�. oti� 2750 Kelley ParkwaY Plan review fee: <br /> L�'kESH 4� Orono, MN 55356 <br /> Total Fee: /5�, O 3 <br /> Main: 952-249-4600 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��SS / E <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �.�Qi;�n1 �/�SS� <br /> Phone (day): 2 - <br /> Address: `<z=�s/SL.�" .�.�f/.J CitY� Q.�O�cJO ZIP� ����� <br /> . <br /> Email and/or Fax i t`I /�,S'��_�_�S�T o���(�ti <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <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) � ��L ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> "'Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review& 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) $ �, �o <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />