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• - r <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: a0 � _�� <br /> Oq, PO Box 66 Permit number: <br /> � `vQ Crystal Bay, MN 55323-0066 Date received: "�.Gl'�3 <br /> Street Address:' Received by: �65 <br /> -� �- 2750 Kelley Parkway Plan review fee: �1 �, g� '�Q <br /> yF� �` Orono, MN 55356 ���pDa$ <br /> '�KFSHo��' Main: 952-259-4600 Total Fee: � <br /> 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: 2�077 �i1 S<C� PD��T i?DA4 <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. Shutt/e 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 INFORMATION: <br /> Name: f.1/ 1fl Bt�l t.DEQ.� 1�l - <br /> State License# BG G 3 77oZ Expiration Date: 3 -'3 I � �01�} <br /> Phone: cell �ol - '7 - C� office l2,- � C <br /> Mailing Address: Cit : �.I�i'c�M•�• ZIP: o� <br /> Contact Person: '��.�_� I�eV�S�NI , Applicant is: ontrac / Homeowner (CircleOne) <br /> Email and/or Fax: � ��.�� �4�10 6V 1WERSMNL CUMt QSZ- q�� ��433 <br /> PROPERTY OWNER INFORMATION: <br /> Name: �11.L +� .�uL.��c �Y�� <br /> Phone(day): t�p7 . yN� - (r¢42 <br /> Address: � Pp�.a Rd Cit : q ZArTA ZIP: ��'�'t� <br /> Email and/or Fax (��n� C„r � w� Lart <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: ^ <br /> PROJECT INFORMATION: Description of project: <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 ❑ Garage/Accessory Bldg. � Public Sewer <br /> ❑Accessory Building �Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify)sM4k1-� �ds�� ❑ Multiple Family/Condo ❑Warehouse <br /> G 1"IAI��.CS � F1LtAvT ❑ Public ❑ Storage � Public Water <br /> *"Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ � � ��• p0 <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />