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, , <br /> . <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: a -L,U�`a � <br /> ��,�. PO Box 66 Permit number: ,�(. <br /> Q � Q Crystal Bay,MN 55323-0066 Date received: ��� <br /> __.__,. � . <br /> • _. <br /> a `� �, Street Address� � �---- --. <br /> ,�, . ~� ,�. <�20/�_OD��, 1 �;� <br /> �c, ' Gti 2750 Kelley Park ay � C� � plan review fee: � a� � <br /> t Orono, MN 55356�__ �� <br /> 9kESH0¢� - -------- �_�— <br /> -_--'" Total Fee: �-`'� (�� �� " - <br /> Main: 952-249-4600 Fax: 952-249-4616 �rono mn.us .L�3C�py�/ t�(,(.�d sZ50� ��Z' C��� <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: ; .� �r^�r I <br /> Job Site Address: ; � � �� Y l � <br /> Will tftis be a Parade of Homes, Remodelers Showcase Home or other splay Home? ❑ Yes ❑ No <br /> If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-peimitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: n /� <br /> Na me: !�(l i'/�C�`f'f" t� d" � N G C..0 <br /> State �icense# e. OD $O Expiration Date: 3 I � D /y <br /> Phone: office cell <br /> Mailing Address: O o D/f D Cit : � ; ZIP: S <br /> Contact Person: v Gv.' G A plicant is: on rac o / Homeowner �c�►�iea,e� <br /> Email and/or Fax: V e �,' D <br /> PROPERTY OWNER INFORMATION: L <br /> Name: E R � l'� /l/A FS t-A D ��� k = �Q S� �� I��I S� C�� <br /> Phone (day): �'s� — 9�7- $93 <br /> Address: �,3 70 C H Q A R ^I /'�p C� City: � R DIV D ZIP: �S S 3 (o�/ <br /> Email and/or Fax 9S� - 9',3'7 - S/.s <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: S A L �A f�l Rc H�fie��S, � /�/G <br /> Phone (day): /�SI- 3S/ —09�01 <br /> � Address: Qp� Soccy't+ FD�IR't'l�S�, CitytSr'llr,ilaTeR ZIP:.SSC�$Z <br /> Email and/or Fax: �Sf -,�5-/ -73�7 <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal� <br /> Water Supply <br /> f$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) ❑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.o <br /> Estimated Construction Valuation (excluding land) � � ! �� `� �r �' , � �� <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />