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`�p CITY OF ORONO <br /> i <br /> , s BUILDING PERMIT APPLICATION <br /> FOR NEW STRUCTURES OR ADDITIONS <br /> �0�� Ma���PO Bo�66 � Permit number. �U��`(��Q <br /> Crystal Bay, MN 55323-0066 Date received: �- Z��-�� <br /> � �, Street Address:' e • , <br /> F Gti 2750 Keiley Park y t�;�r /'_�� Plan review fee: ,q C <br /> t.qK�'SHo�� Orono, MN 5535 ��� � <br /> Total Fee: <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 wili be returned. (Please print) <br /> GENERAL INFORMATION: � <br /> Job Site Address: 7(�,S �o%3 �B�°`K �' �. �,� ,' v �f//yAop,1'�e, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ No <br /> lf yes, a special event permit is 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 I MATION: <br /> Name: - � { <br /> State License# � Expiration Date: 3 3 � <br /> Phone: cell - ,g- office S - s'D 3 <br /> Mailing Address: Cit � ;,,,,.�r,.,�,,f ZIP: S' <br /> Contact Person: c!�/w•�e T<<c, s Applicant is: Contractor / Homeowner (Circie One) <br /> Email and/or Fax: �'�v,� � � e e �Q�/� � p�� f , o� <br /> PROPERTY OWNER INFORMATION: <br /> Name: .S T�,,,� 6,a,a,eiC De v C L C' <br /> Phone(day): QS � � S 5�.��-d y3. <br /> Address: �// � g� � � ,� D.�. City: �.��,�.� Twa..ZIP: SS 3�3 <br /> Email and/or Fax ST� v � r B.. Ge9 00 .�r �� 'L.�r�w �"o ...�-... <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: ^ <br /> Phone (day): Z. - 3�,r . p <br /> Address: // Cit : .�....,�� Tv.�.,t',�ZI P: � ,3 y <br /> Email and/or Fax: ^ v Q '� c wi . ....�-. <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> New Construction Water Supply <br /> ❑ Single Family with Residence / <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. [.�'i'ublic Sewer <br /> ❑Accessory Building � Single Family with ❑ Deck <br /> ❑ Relocation hed arage ❑ Office/Commercial <br /> ❑ Other: (specify) [�il �� ❑ Warehouse � Private Sewer <br /> ulti le Famil /Condo <br /> ❑ Public ❑ Storage Public Water <br /> **Any earth movement may also require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial <br /> Minnehaha Creek Watershed District MCWD ❑ Private Well <br /> ( ) ❑ 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) $ �� Q d Q � , <br />