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<br /> City of Orono
<br /> .
<br /> � Building Permit Application ��� ��
<br /> for New Structures or Additions
<br /> Mailing Address: Permit number: 020/07� �l�S��
<br /> g,0,�. PO Box 66
<br /> Crystal Bay, MN 55323-0066 Date received: (9-1�l- ��-
<br /> 0�..:��..:, � S
<br /> I _ � Received by:
<br /> �,a, "�'�� �, , Street Address:
<br /> '�'�c, �� �w 2750 Kelley Parkway Plan reviewfee: q�0�a� -(Jp s�v�
<br /> \l.�E•� `fi ¢� Orono, MN 55356
<br /> �:_sHo. IO S.�,fj �J�
<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 will be returned. (Please prinf)
<br /> GENERAL INFORMATION: �, , � .� ,
<br /> Job Site Address: �u= � l �-�t'�in ' � ,;-�-t �'�l
<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 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 I APPLICANT INFORMATtON: �
<br /> Name: 11'l N �t S L- � �1 :., � , �i
<br /> State License# �:j;' j�� 9 .$'3 '� Expiration Date: �- 3��� �Qf�
<br /> Phone: O 4�/ - < < t-- e> " ` office cell
<br /> Mailing Address: �,��>�,�. :::r�,�r L�-,.. r City: �v r� -, ZIP: f'; i� 7
<br /> Contact Person: � ,.►'1 r-�r� S Apphcant is: �ontraCtor -/ Homeowner (Circle One)
<br /> Emailand/orFax: ��'1/i %tS, 1Y'�z-,c '� _ ��-�,�;./ C , ,:•
<br /> ---.
<br /> PROPERTY OWNER�NFORMATION:
<br /> �.
<br /> Name: �-.�;� ��5 // ,,�r���l,�,�
<br /> Phone (day):
<br /> Address: i s.� :,:,�,, '�.;- /%'� Cit : c=.- �. , c ZIP:
<br /> Email and/or Fax � r>,., �; // ,� , ,..��� ,;.� / , �� :.�
<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 �5+�c�5 ❑ Single Family with � Deck =-
<br /> ❑ Relocation p � � 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 /> Deephaven,MN 55391
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.or
<br /> Estimated Construction Valuation (excluding land) $ � S' `� `� � /
<br /> I �
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