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� <br /> , <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> � Mailing Address: Permit number: ��(�—� a <br /> �,i,�,��� PO Box 66 .y <br /> Q � O'\ Crystal Bay, MN 55323-0066 Date received: / � <br /> �4� <br /> a �`'.���;'" �, StreetAddress:' Received by: <br /> � ��'a��� <br /> `�� '��q�,� �,ti�' 2750 Kelley Parkway Plan review fe <br /> \L9kESH�4� Orono, MN 55356 � <br /> Total Fee: a%�� � <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: Q J <br /> Job Site Address: ���p� � , �20(•vf� I�OG�C` <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a specia/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/APP�LICAN INFORM ION: /� ' ' <br /> Name: I Vo � ���r.(?sa�rr`s C�-�`�'t[n�s <br /> State License # �-D(0 3 � 1.s Expiration Date: 3 ?�D (L-- <br /> Phone: (pt Z- Z - 7 office cell) <br /> Mailing Address: p P�1 . 1- r� Cit : ZIP: S.� <br /> Contact Person: [,�,� Applicant is: Contra tor / meowne (Circle One) <br /> Email and/or Fax: �Lo_�nOT��a.t"h <'u r�f'ar1mS � �01�v� <br /> PROPERTY OWNER INFO ATION: <br /> Name: p S <br /> Phone (day): — 2 r G��' / <br /> Address: crh�n �� Cit : l.� ZIP: Sj�,�j�� <br /> Email and/or Fax _ � ��,� �r�_��`�� _ �j�,� <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: Cit : 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 /> ❑ A ition ttached garage �Garage/Accessory Bldg. ❑ Public Sewer <br /> ccessory Building �ingle Family with ❑ Deck <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. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deaphaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ � p� , dp <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />