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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: � <br /> .g,�,�. PO Box 66 Permit number: D�� —ODa- <br /> O O Crystal Bay, MN 55323-0066 Date received: '� !� <br /> ,� `�' �, Street Address:� Received by: ' <br /> � �~� ti`� 2750 Kelley Parkway Plan review fee: Z.� � _I t � <br /> �'t.q�E$HOg,�G Orono, MN 55356 a.013—��aD � <br /> Total Fee: � . <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (�•(�Q •Z,' <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returne . (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 2 7�/ `� �/��<<-% � J <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 wilf be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLIC T I FORMATIO �� /� <br /> Name: � P�� �t l �Q'��' < cy r <br /> State License# ` � �;� Expiration Date: 2t�/ �% <br /> Phone: ;Z " 7 j office —� cell <br /> Mailing Address: � / ' , e c. � � Cit :' y c� ZIP: ' 3" ' <br /> Contact Person: �� Applicant is: racto / Ho eowner (Circle One) <br /> Email and/or Fax: �_ ' � ��,. i ' I2 Z5�' <br /> PROPERTY OWNER INFORMATION: .� , J � ' <br /> Name: Co �, �� �d e�� c n�-�.�/� �� C- c�c � � �v� <br /> Phone (day): Z. � �� �% <br /> Address: � ; ,- Cit : � ZIP: S� � <br /> Email andbr Fax � ,- �• ; � • ra c r � l :� ic� <br /> ARCHITECT/ ENGINEER INFORMATI N: <br /> Name: ��'�✓ �S�"%1 <br /> Phone (day): �-L � � — 7d L <br /> Address: Cit : ZIP: <br /> Email and/or Fax: �t � �' bp �^ ' r�A� �n�c� � c�s i�t� � L t�l� <br /> _ ,__ � __ J <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 �sidence <br /> [�ddition Zv�C� �7'��''Y attached garage ❑ Garage/Accessory Bldg. Public Sewer <br /> ❑Accessory 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 /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> c <br /> Estimated Construction Valuation (excluding land) $ l�d Q L�D <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />