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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> �T PO Box 66 Permit number: �/5- d��� <br /> ��`V O Crystal Bay, MN 55323-0066 Date received: f �� �—�� <br /> � StreetAddress:' Received by: <br /> � ,� 2750 Kelley Parkway Plan review fee: �' S�� <br /> F� c,` Orono, MN 55356 �� 5-_ �-�-� — <br /> �KFS}{O�� Mai n: 952-259-4600 Total d <br /> Fax: 952-249-4616 vNrr�.ci oror�; ^�n �_,s �' <br /> This application form must be completed in full and all required infor atio t be sub ' �. <br /> Incomplete applications will be returned. (P/ease �nt) �� �' 3 <br /> GENERAL INFORMATION: -- - <br /> Job Site Address: ��� � C=���`>c-�% �-�f (�� <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 ill 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: ��(� �' Z-( Z '��C��.S�]?t�i''�t <br /> State License# {-(ul��t� c>�,�;,.,�1Z. Expiration Date: <br /> Phone: (cell) (� l,� – �SU �-- �'1 S�c• (office) <br /> Mailing Address: (F,t� �15� � f T (z.P Cit : <br /> Contact Person: L."�� L'���-S�7G �� Applicant is: Contractor Homeowner ircle One) <br /> Email and/or Fax: � <br /> PROPERTY OWNER INFORMATION: <br /> Name: �12-�L_ ��'Ca5'��or�l <br /> Phone (day): (f, l .-� :�S� �'f �r�U <br /> Address: ��� ! `� ��+5�c� ��i j�� City: l.� ��7 i1'i 1� ZIP: ��S�i j <br /> Email and/or Fax �1���(L f1' �✓�'�aSi iz � �'� � c��m <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZI P: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of pro�ect: <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 ��arage/Accessory Bldg. Public Sewer <br /> �ccessory Building ❑ Single 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 /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ��� ��'� —' <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />