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_ , i .+, <br /> City of Orono <br /> Building Permit Application �e�� ��d�� t <br /> for New Structures or Additions P �' <br /> g- UD 7 <br /> �— Mailing Address: Permit number: O -�(��-7S <br /> �g,�,� PO Box 66 <br /> �� �� 0�� Crystal Bay, MN 55323-0066 Date received: � ! 1 ab09 <br /> ��� � Received b � �/� <br /> a � :4,!�;�., a, StreetAddress:' Y <br /> �� ' "4� Gti 2750 Kelley Parkway /� Plan review fee: � UgQ- $� <br /> ��'kESH�g'� Orono, MN 55356 !�t��Q� ��0.f1 rCV��: ,�d�"�!-��� <br /> Total Fee: ---- <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us f� �" <br /> � <br /> This application form must be completed in full and all required information mu t be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: //� Cft�/c /�,�/� �f,f <br /> Will this be a Parade of Homes, Remodelers Show ase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �� ��.s,e �i/�eo 4�✓is`i:�, � 1.r c, <br /> State License# Z,os� S��19 Expira ion Date: 3-$ /-20�0 <br /> Phone: 9 SZ- 8 S(o- 5�b�l (office) 9 sz - Z 3 7- 3 3 4�0 (cell) <br /> Mailing Address: �3S S f'�vt� Qo.d Citv� cyGsk4 ZIP� s'`s3 �8 <br /> Contact Person: pcc�„ -7-eti„sa„ Applicant is: Contractor / Homeowner (Circle0ne) <br /> Email and/or Fax: .I'��'dl,n_,san � 7`fon►c�,,,Q c a.., <br /> PROPERTY OWNER INFORMATION: <br /> Name: �yq��v ��jn,l'o.s <br /> Phone (day): 7G 3- '7�5�— 7/2 3 l <br /> Address: [�10o Wn,•�G•�Sj-on2 ��qc.�, City /Y��aq�,�h(G� ZIP� �,s'30 S l <br /> Email and/or Fax 9,5'Z-c(�2- y7�{2 <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: /h�I�a. fharr�7"l" ��o ti <br /> Phone (day): �j� - t.�70 - 9 7So <br /> Address: y�y ,Sa.e,�d Srtrc.¢t .S4i�C. / Oa Cit : CXc�IS% dy z�P� Ss 3 3� <br /> Emailand/orFax: _ Www� �tiqrra�ld�.Sion co�► <br /> ✓ <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 ❑ Office/Commercial <br /> ❑ Other: (specify) ❑ Multi le Famil /Condo ❑ Private Sewer <br /> p y ❑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) ❑ 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) $ y�c0� o00 <br /> -20 - <br />