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, . ! � <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: ,�D6�- <br /> /��,��� PO Box 66 Permit number: <br /> /i Q �` ��\, Crystal Bay, MN 55323-0066 Date received: g��—Q <br /> 'I '�r �I <br /> ��� ���✓��s-;;; a,�; Street Address:� Received by: <br /> '��'.�c, %�}:;� �;�'.� ��ti ' 2750 Kelley Parkway Plan review fee: � —QD 5.3 <br /> �L `"��Yt�'��r�� Orono, MN 55356 3 • � �,� <br /> ?fEsxoi 7 3 ��,3�. <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. /'�o! <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERALINFORM O • , , /� <br /> Job Site Address: �� J (_,��� SC� ��l N�- /\C�c?' � <br /> Will this be a Parade of Hom , Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required witls,Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates suffici�qt on-site parking rs available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMQTION: <br /> Name: �e( � <br /> State Lir,snse# Expiration Date: <br /> Phone: (office) (�ell) <br /> Mailing Address: Cit : ZIP: <br /> Contact Person: Applicant is: Contractor ! Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION1: <br /> Name: C� � FFC�v_�D � �a r'�0 c�b`� ��,�)�/�l SO/'Y, <br /> Phone (day) �j S,�- y��/� ��j ai'� � <br /> Address: a, �.� CF�S�b j.�r���T Z�'� 1 <br /> � `f' /��C� City:C,U�`Y � ZIP: S_S .��� <br /> Email and/or Fax C�� , FF SW eNs��'V ' S� COf�� <br /> ARCHITECT/ ENGINEER INFO�ATION: <br /> Name: ��-_(� <br /> Phone (day): <br /> Address: Cit : 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 ara e Gara e/Accesso Bld <br /> 9 9 � g ry g� ❑ Public Sewer <br /> ❑ Accessory Building ❑ Single Family with Deck <br /> [�Relocation � detached garage ❑ Office/Commercial <br /> �ther: s eci ,,v ❑ Private Sewer <br /> ( p fy) ❑ Multiple Family/Condo ❑Warehouse <br /> �j'[� ❑ Public ❑ Storage �Public Water <br /> '`*Any earth mov ent may require ❑ Commercial ❑ Other(specify) <br /> MCWD review permits. ❑ Industrial <br /> Minnehaha Creek Watershed District MCWD ❑ �ivate Well <br /> ( ) ❑ 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) $ ��j,� <br /> Last Updated: 9/29/2009 , w <br /> - 17 - ���UQ � '����� 1: . <br /> ,�-^ ! � ,:� : .. <br /> � - �1t��f� _� <br />