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, City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: J <br /> �.,�,� PO Box 66 � � ��mit number. D//— (x'` ((70� <br /> Q �� Q Crystal Bay, MN 55323-0066 �� Date received: <br /> Q <br /> � �4�^�-�'' F � StreetAddress:' ��.�eived by: 1�� � �,�y <br /> �� ��ti 2750 Kelley Parkway � �PI`ar5 review fee� � /�Pf:l:�: �" 7;�� <br /> �kESHO�`' Orono, MN 55356 �� ti-��� �����,� <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. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: eV ,•- � <br /> Will this be a Parade of Homes, Remodelers Sho case Home or other Display Home? ❑ Yes No <br /> If yes, a specraf 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 demonstrafes sufficient on-site parking is availabfe. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �ccucr R u;(d;►�.o, LC.-C� <br /> State License # Expiration Date: <br /> Phone: C- (vlZ- $6 a- 5bq office (o _c�7 _Z� cell <br /> Mailing Address: t(�2� S r, Cit : u l� (a 'v� ZIP: 35 <br /> Contact Person: � Q„� '��`�c,� Applicant is: on ractor / Homeowner (CircleOne) <br /> Email and/or Fax: ��3^ y�� _���� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �oo�� �cw�.arlL l.P(Z- " ��0 - �'L� <br /> Phone (day): �jSZ- 4��z_ n 77 7 <br /> Address: 1`� ( GLt��/w �� ¢_ �r'� City: DVO rl p ziP: 55 3� 1 <br /> Email and/or Fax (�yy�a� `'lt C�i't'1 <br /> � �S <br /> ARCHITECT/ ENGIN ER INFORMATION: <br /> Name: �e Kd�/ e � ,� " .�o v <br /> Phone (day): Z - _ <br /> Address: �d ( F , L���7 S',.{; City: w �,„�2q��q ZIP: �53� � <br /> Email and/or Fax: <br /> Q <br /> PROJECT INFORMATION: ,��� � r �� � �- <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal & <br /> Water Supply <br /> ❑ 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 8�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 /> Estimated Construction Valuation (excluding land) $ -- <br /> Last Updated: 4/26/2011 r � • <br /> - 19 -�I «-�L=F3 1..�0.S 5�.7 i�-}- 1 �- ��1'Y�1'� <br /> ��c�.,�.se �:�- h o�d v� Grn <br /> •�,s �r-t=►�sr vf p�rrn i� <br />