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City of Orono �� <br /> Building Permit Application � 1� � <br /> for New Structures or Additions <br /> Mailing Address: �v�� <br /> ���0 PO Box 66 ( Permit number: <br /> Crystal Bay, MN 55323-0 `�, Date received: ��' � <br /> V' <br /> Streef Address:' �I� Received by: <br /> -� ,� 2750 Kelley Parkway <br /> yF ��, Ptan review fee: <br /> c,` Orono, MN 55356 ' � <br /> l�KESHO�� Main: 952-259-4600 Total Fee: <br /> Fax: 952-249-4616 wvwv.ci.orono.i�n.us <br /> This application form must be compteted in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �,G I O �c���v� r�✓�', ��o vr�r , � �� vr .���� _ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or ot er Display Home? Yes No <br /> !f yes,a special event permit is required with Police Department and City Counci!approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events will not be apowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (cell) (office) <br /> Mailing Address: Cit : IP: <br /> Contact Person: Applicant is: Contractor / Homeowner �ci�ae o�e> <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: p <br /> Name: IQs l 'u f ��t �c��r , <br /> Phone(day): ,� � "', �� <br /> Address: UiU -/H �,.�� Cit : G � � ZIP: ��.��� <br /> Email and/or Fax h �-a � p ���✓yr c�; !, C c�r» <br /> ARCHITECT/ENGINEER INFORMAT ON: <br /> Name: `��l P .S�t Nv S��i� <br /> Phone (day): — 3 / <br /> Address: s -1 , . �-�c.� Cit : (.���r � /.�G�r ZIP: s /� � <br /> Email and/or Fax: e h l,c a � �i K,` � C,a <br /> PROJECT INFORMATION: Descri tion of ro�ect: <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 ❑O�ce/Commercial (�j 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) [�Othe}': (SpeC�Y) I <br /> 18202 Minnetonka Blvd 4i Q EK U,���( �Y�e�� <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek or <br /> Estimated Construction Valuation (excluding land) $ �, O /Q • �G <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />