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I C i ty of O ro 0 Building Perr�it A plication - � for New Structures r Additions Mailing Address: ��(� -- �.'f�� �/�.,O,j� PO Box 66 Permitnumber: � � Crystal Bay, MN 55323-0066 Qate recei�ed: � '- � �' �� �� ` Received by: 1,a q �t�-: �,�; Streef Address:' �— � -' �'1 ��' �' �`�� ti% 2750 Kelle Parkwa oc:� ,�/g � q# �' „i a��a c, Y Y ��J Plan review fee: '� ��`� '� Orono, MN 5535 Dl� ' C'� \�'�Esxo�``'� �z a Pa s��.D1�-F��t�us+-�-r�s+� `yc�u r.�s:�-�. ' — � �� Total Fee. Main: 952-249-4600 Fax: 952-249-4616 www.ci.oro o.mn.us This appfication form must be completed in full and all r quired information must be submitted. fncomplete appiications will be ret rned. (Please print) GENERAL INFORMATION: Job Site Address: �y� fj�i� ;� S�� < Will this be a Parade of Homes, Remodelers Showcase Hortne r other Dispiay Home? ❑ Yes ❑ No If yes, a specia!event permit is required with Police Department and City Council appr val 60 days pnor to the event. Shuttle bus service will be required unless applicant demonstrates su�cient on-srte parking is available. Non-per ifted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: State License# L-�C� Expiration Date: Phone: ' office (cell Maifing Address: City: ZIP: Contact Person: Appfic nt is: Contractor / Homeowner (CircYe One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: /{ �� T ��,C�S�n Phone(daY)� �_ �5-�� c7/-/�� Address: �/ i �r Y Si r /zc-�� Cit : �� ZIP: Email and/or Fax ARCHITECT/ ENGINEER INFORMATION: Name: — Phone (day): Address: Cit : ZIP: Email and/or Fax: PROJECT INFORMATION: 1.Type of Project 2. Proposed Use . Structure Type 4. Sewage Disposal 8� Water Supply ❑ New Construcfion ❑ Single Family with Residence �Addition attached garage Garage/Accessory Bldg. ❑ Public Sewer ❑ Accessory Building ,��Single Family with Deck ❑ Relocation � detached garage Office/Commercial �rivate Sewer �Other. (specify)��i�� v C'C?� ❑ Muitipfe Famify/Condo Warehouse ��f¢�r�> ,' D/�t/ �X i 5 7-i�t� ❑ Pubiic Storage ❑ Public Water ""'Any earth movement may require / ❑ Commercial ther(specify) L` MCWD review& permits. ��'�'h ❑ Industrial cF n �a (7 �Private Well Minnehaha Creek Watershed District(MCWD) ❑ Other:(specify) 18202 Minnetonka Blvd , �/ � X � S � l�"�5 Deephaven, MN 55391 Phone: 952-471-0590 �� C' � Fax: 952-471-0682 www.minnehahacreek.or Esfimated Construction Vafuation (excluding land} $ I p � `""