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(� Y °�` � City of Orono � �� , '�' �� w ,� Building Permit Application �� 7�, 0� for New Structures or Addit'o � ;� l jz;��''�°r'-`� Mailing Address: � PO Box 66 v�, rmit number. v7 Ol 5 " ` � �� Crystal Bay, MN 55323-0066 � Date receive¢��"�' D--/��l..s�.c Street Address:' � � ,�- 2750 Kelley Parkway V �� < y�' c,` Orono, MN 55356 �C � .-, Fl�n review fee: tqkfSHOQ'� Main: 952-249-4600 Total Fee: Fax: 952-249-4616 :v�h�'w.ci urur�o.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print�N� � I�Y1.el. �SC'-rou% �� GENERAL INFORMATION: � r.t.seD --�� t'S-f2�9Z.1 Job Site Address: ;�,�'�� ',r�'„-�c�_� �u� '�C� ��a�, �.U^_� za`�cz:; 11^ P� 5 �;3�� _ Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No 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 required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: '` �J �I �.� ' Y:.'c; iC C, . State License# �t�� [..; S I :i Expiration Date: 3 3% Phone: (cell) f,�2•� 1 Z I - ,S�'n `� (office) �s;�_ y�y_.�, �7�, Mailing Address: 7p n- r�v Cit : p-� �_ 13n � ZIP: �� ° � Contact Perso � �-F c,V� �i s h��r' Applicant is: ontractor / omeowner ✓(Circle One) Email and/o Fax: �$ . _ C a� S �,��ci ` ' "�;u' ` ^ � %✓�. " m PROPERTY OWNER INFORMATION: Name: `.j v '�f; L�.V�S i r+� Phone (day): _ S _ ��y Address: �;,y; �l-y ��ta ( B��, (lo�x� City: (;JayLa�G� ZIP: $S�3`l� Email nd/or Fax (�.h��1�, ;✓►��=, ��) 'l rr�ci 1: C,�rrr� ARCHITECT/ ENGINEER INFORMATION: Name: �'Ci��-� (,r�i-, Phone (day): �� E i 2.- ��<� -� 'j 7 7 �r+�r c�.� 6�Z - ��.7-� � f C i" � Address: ;,��5 �"u st SOt"� �rt' City: f1;;; ��ar,F�/�� ZIP: „S t( f � Emai and/or Fax: Gr�'r. Z r � �%o i , �.�-'�r� � -/ PROJECT INFORMATION: Description of project: / � � ��l � , � ��C1 � 1.Type of Project 2. Proposed Use 3. Structure T pe 4. Sewage Disposal & .�� Water Supply Q New Construction �Single Family with ❑Accessory Bldg./Garage �,Addition attached garage ❑ Deck �Public Sewer ❑ Accessory Building ❑ Single Family with Office/Commercial ❑ Relocation detached garage �Residence ❑ Private Sewer ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) ❑ Public 4-feet or greater �Public Water "Any earth movement may require ❑ Commercial ❑ Storage MCWD review&permits. ❑ Industrial ❑Warehouse ❑ Private Well Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify) ❑ Other(SpeCify) 15320 Minnetonka Blvd Minnetonka, MN 55345 Phone: 952-471-0590 Fax: 952-471-0682 www.minnehahacreek.or Estimated Construction Valuation (excluding land) $ ;'� , ��O<, � Packet Last Updated: August 2015 Page 21