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t '�. <br /> ._ - ' t �tJ <br /> . . (� '� , o� <br /> �/ �1 r n <br /> � Cit of O o 0 <br /> � . I� y <br /> Building Permit Application <br /> for New Structures or Additions �` s��. 7 S <br /> Mailing Address: Permit number: oZdD —DO /� <br /> %g,�� PO Box 66 �� �, <br /> � Crystal Bay, MN 55323-0066 Date received: L=' �� <br /> � 0��� ���� <br /> I Received b G�� <br /> � � y: <br /> ,� Street Address:� � r �. <br /> �'� �� ���� ��� 2750 Kelle Parkwa <br /> , �! Y Y Plan review fee: .:.� <br /> � <br /> �ly'`�3������'� Orono, MN 55358 <br /> \��k��o/ �ia.n. �v� �.o 0 9-o o�7 3 <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: ��dp i3r1.qC,�CE-,�'f`��a�,�T-- �o.4L� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> If yes, a special 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 demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: C H�RL.t.�'S �t.1p� �,o . <br /> State License# ZoCc 3SZ�--S Expiration Date: 3- 3 1 - Zdld <br /> Phone: Cn/Z- 33 3 - �3020 (office) (cell) <br /> Mailing Address: b ad . Cit : �ouTr3 Z�P: SS <br /> Contact Person: ��-1/� (..�Gt�'t-" Applicant is: .Con r c o / Homeowner (Circle One) <br /> Email and/or Fax: �J L T- C q�,(�-SC t1�J , c " Z- - Z� <br /> PROPERTY OWNER INFORMATION: <br /> Name: F�Iz[.cLE [J�10t�OG[C <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: j�.4u,x-r�l�7L � ,�o �1Cffit�,uD <br /> Phone (day): �/Z- �3 S�- /}�� <br /> Address: �julTG s�i , 2?s �s�rzk�`r- Sr� c�ty: �►?�,���apd��SziP: 554�5 <br /> Email and/or Fax: x, , j 2- 3 3 a -- }C�O S <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 Sewer <br /> ❑ Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ O�ce/Commercial ❑ Private Sewer <br /> �Other: (specify) ��`t�on�-- ❑ Multiple Family/Condo ❑ Warehouse <br /> �—k�g7taC�j �j�q�-f' �p<„!r-,,�" ❑ 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 'Rt�'7�(p�C_. <br /> Deephaven, MN 55391 �.,x�5��� <br /> Phone: 952-471-0590 t�- <br /> Fax: 952-471-0682 �p"r 1-r���' <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �2,2� (�04. -- <br /> Last Updated: 6/22/2009 <br /> - 19 - <br />