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City of Orono <br /> Building Permit Application ���� I I Z-- <br /> for New Structures or Additions �IU�IA 1� � <br /> _—�, Mailin Address: <br /> /�L+y 0.�� PO Box 66 Permit number: ,20/�- d � 7�— <br /> /Q �,� �\ Crystal Bay, MN 55323-0066 Date received: �d" /�J - // <br /> / � �� <br /> I•� �''� " ' s, Street Address:� Received by: <br /> ` k'�'=�_ <br /> ��t���` rv�~ 2750 Kelley Parkway Plan review fee: q?0//—D �2�/ <br /> ��ESHo4 Orono, MN 55356 ��� <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 print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ���,�j n�.� � �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> If yes, a specia/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 su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: U��� <br /> State License# _� �'S� 5 Expiration Date: 3-�i -(,1 <br /> Phone: _ _ office cell <br /> Mailing Address: '"J Cit : w � ZIP: 34 <br /> Contact Person: ��,� l� �v�v,na�� Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: [�,.�,r, ,s� (,�,r,�. h�� ��., �_ 4���4�_r�;E1�S <br /> PROPERTY OWNER INFORMATION: <br /> Name: �� c� l��vv�rY1�S <br /> Phone (day): --7�,-� _ ���,_ � �� <br /> Address: �� .'['_o���c.y�_ �P-�, City� c�71ra �e. ZIP� �'35�, <br /> Email and/or Fax �x --Z�;�_ ��_ i�-� <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: Sc.�ti G2.; �-- <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 8 <br /> Water Supply <br /> � New Construction � Single Family with �.Residence <br /> ❑Addition attached garage ❑ Gara e/Accesso Bld <br /> ❑Accessory Building ❑ Single Family with ❑ Deckg ry 9' �Public Sewer <br /> ❑ Relocation detached garage ❑ OfficelCommercial <br /> ❑ Other: (specify) ❑ Muiti le Famil /Condo ❑ Private Sewer <br /> p Y ❑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) $ ( ��y�.��� <br /> Last Updated: 9/29/2009 <br /> - 17- <br />