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- City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: O 1� —�O a� <br /> O.¢,�,�.0 PO Box 66 r <br /> Crystal Bay, MN 55323-0066 Date received: `' � 1� <br /> � �� <br /> � ' �, �., Street Address:� Received by: ��'t,'!�r , <br /> ,�, � Gti 2750 Kelley Parkway Plan review fee: Z.� - J _I ' � i <br /> LyxESHO¢� Orono, MN 55356 a,0 f 3-ooao � <br /> Total Fee: � . <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (�•pQ •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: � �� `� ��5�v �/' / <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 1 APPLIC T I .FORMATIO • � <br /> Name: � �rf ��, �cY�� �d r <br /> State License# ` �/ �j;� Expiration Date: ZC�� � <br /> Phone: 5 Z 7 j office —� cell <br /> Mailing Address: � / ' ; �c. J� Cit " � o- ZIP: ' 3 <br /> Contact Person: �F�- Applicant is: racto / Ho eowner (CircleOne) <br /> Email and/or Fax: r K -�,. + J 2 Z5�' <br /> PROPERTY OWNER INFORMATION: <br /> Name: �) � � e�� �� wtc>� �� � c�c � ^� �+'L <br /> Phone (day): Z � �� � �f <br /> Address: �; � Cit : � ZIP: S� � <br /> Email and/or Fax � ' r c i • r�1 c ; � o l' :� i� <br /> ARCHITECT/ ENGINEER INFORMATI N: <br /> Name: ��'�►� �S :.. <br /> Phone (day): �L —� 7 — 7� � <br /> Address: Cit : ZIP: <br /> Email and/or Fax: )'1�l � � e r ' r�� �n�ct k ��S'r��� � Cv+� <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal 8� <br /> Water Supply <br /> ❑ New Constructio ❑ Single Family with [��sidence <br /> ��ddition "7�� �7'��''`( 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 /> v <br /> Estimated Construction Valuation (excluding land) $ j�d ��4 <br /> � <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />