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<br /> City of Orono � �'` � -�
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<br /> Building Permit Application �
<br /> for New Structures or Additions
<br /> Mailing Address: Permit number: ��/p�—�`� a��
<br /> .�0,� PO Box 66 /
<br /> Crystal Bay, MN 55323-0066 Date received: �1`"�—! �
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<br /> �',,� �"'l��� -+` ,, , Street Address:� Received by:
<br /> \`� �.,fij: �ti 2750 Kelley Parkway Plan review fee:
<br /> \r ' ,� '�fi'���� Orono, MN 55356
<br /> '�Esxo4`' �
<br /> ,:�=_=-- ��5 5 �
<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: '� 3� � a
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<br /> � C°,L� � � �� � ^ L,.�;' ` r'c;v� , ��
<br /> Will this be a Parade of Homes, Remodelers S owcase Home or ot er 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: S�{-4-- '}��•,.,�,�.
<br /> State License# Z�,�, Z��,_� Expiration Date: �<;, ��
<br /> Phone: � ��- ��i q-��f3:� (office) Y�Z-��l - �(� y y (cell)
<br /> Mailing Address: �,,. � Cit : � � . ,, ZIP:
<br /> Contact Person: � Applicant is: C ac or Homeowner (Circle One)
<br /> Email and/or Fax: � ��-(- �'�,�;�'Nt„-��,,,�,-A,cL� �v v�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: )-�-w� ��r`�c.y�-e�
<br /> Phone (day):
<br /> Address: Z 3 S C� ,. �,�., s�• � 1(]'�' � City�'L�;�. r�, ZIP:
<br /> Email and/or Fax
<br /> ARCHITECT/ ENGINEER INFORMATION:
<br /> Name:
<br /> Phone (day):
<br /> Address: City: ZI P:
<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 �5ingle Family with �"�esidence
<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) k:��t�--�:� -�.r ❑ Multiple Family/Condo ❑Warehouse
<br /> ,,,>���� ❑ Public ❑ Storage ❑ Public Water
<br /> "*Any earth movement may require ❑ Commercial ❑ Other(specify)
<br /> MCWD review 8�permits. ❑ Industrial �rivate 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.orq
<br /> Estimated Construction Valuation (excluding land) $ /�'� �� C�C�
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