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�S`) <br /> City of Orono '���2�'��� <br /> Buildin Permit A lication �� >�� � � �� <br /> 9 pp �C� <br /> for New Structures or Additions <br /> Mailing Address: Q _QD�� <br /> O�,�,�0 PO Box 66 Permit number: <br /> Crystal Bay, MN 55323-0066 Date received: � D <br /> a -`i a, StreetAddress:' Received by: <br /> ��e, � � Gti�' 2750 Kelley ParkwaY Plan r iew fee: '� �, <br /> r'��Esxo4`'� Orono, MN 55356 �J(��—(�jO 7 9D <br /> --- Total <br /> Main: 952-249�600 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: I <br /> Job Site Address: /�5 ectZ('w oo� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No <br /> N yes,a special event pe�mit is required with Police Department and City Counal apprtival 60 days prior to ti►e event. Shutde bus service "ll be <br /> requi2d unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATIO : <br /> Name: o„� ;�„�; �', ;o,� C� <br /> State License# �o�9o�Loy Expiration Date: 3 � o <br /> Phone: /�- i - office .�,-.� cell <br /> Mailing Address: yi�0 3'+� Q n) Cit : ,,.,, l.. ZIP: S <br /> Contact Person: .,,� ;.�,,. ;�, Applicant is: ntra / Homeowner �c���o�a <br /> Email and/or Fax: � o.., ;.�.S Lo...^ 7�3-�oS- 8 6 4 <br /> PROPERTY OWNER INFORMATIQN: <br /> Name: a�*�c ��aWC .�rSo r� <br /> Phone(day): 9Sa-�5� --v b9 <br /> Address: /PS �c{e�,,,,m�/ Qr City:�ro�o ZIP: 5S3S� <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: /✓l� <br /> Phone(day): <br /> Address: Ciry: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <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 Sew�er <br /> ❑Accessory Building � Single Family with �''Deck <br /> ❑Relocation 1 detached garage ❑Office/Commeraal ❑Private Sewer <br /> �Other. (specify) Uel//`-�-✓1e'� ❑Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑Storage ❑Public Water <br /> *"Any earth movement may require ❑Commercial ❑Other(speafy) <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) S ,6SL D_o 0 <br /> Last Updated: 9/29/2009 <br /> - 17- <br />