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- / ♦ <br /> � � � " <br /> ����. <br /> City of Orono _ _ _...___.._....� <br /> Building Permit Application � � <br /> � � , �� <br /> for New Structures or Additiaris . .3 8 � _� <br /> MailingAddress: Permit number. I� — Q�� <br /> O�,G,�.O PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: D "" /�� <br /> �a\ <br /> �Y <br /> • Received by: <br /> a �, �:t:y a Street Address: <br /> �',�, � �,'� �ti�' 2750 Kelley Parkway Plan review fee: �lJ/02 � �J��� 7 <br /> �o� <br /> '�9k���og Orono, MN 55356 � ��� q� �, / <br /> ——�" Total Fee: � ��� <br /> Main: 952-249-4600 Fax: 952-249-4616 �,r��v���v a orono ;�� <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: (�.(�, <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 approva/60 days prior to the event. Shutt/e bus service il e <br /> required un/ess applicant demonstrates sufCcient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/AP LICANT INFO TION: <br /> Name: -�( � � (Y1C- <br /> State License# 3 b0 Expiration Date: �-j Z J <br /> Phone: � office cell <br /> Mailing Address: � m Ci � ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: 1r�SrG � <br /> PROPERTY�DWNER INFO MA ION: <br /> Name: <br /> Phone(day): (Q� � p 3 <br /> Address: �j Ci : �� ZIP: �� <br /> Email and/or Fax �t mr n � COPY� <br /> ARCHITECT/ENGINEER INFO ATION: <br /> Name: � � <br /> Phone(day): a <br /> Address: �io"2� (� Cit : �� � ZIP: ��� <br /> Email and/or F�ax: r � <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> Water Supply <br /> New Construction Single Family with �esidence <br /> ❑ ddition ttached garage Garage/Accessory Bldg. ublic Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Warehouse <br /> ❑ Public ❑ Storage ublic Water <br /> "*Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�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) � � � � � �6� • d� <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />