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t' �O� <br /> �/ �"�' <br /> � <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: G – Dd 77 <br /> 'gv�.�\ PO Box 66 <br /> � , Q� Crystal Bay, MN 55323-0066 Date received: �� d <br /> �� `��'?�m <br /> ��� ` ���� � . <br /> ���,�s,�;, s.� Street Address: Received by: <br /> ��'�n ���,�It�A�� ��� 2750 Kelley Parkway Plan review fee: <br /> L`�kE�ss i Orono, MN 55356 <br /> i <br /> Total Fee: ,Cg� 35 <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us J <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: � � ���� � �V�� /�p� 1 <br /> Job Site Address: r/ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wrll 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: IQr�,.�.�a.� Lm.tS�vvG���d�--� <br /> State License # �'�z,'� Expiration Date: <br /> Phone: _ _ � office) cell <br /> Mailing Address: /G?�-tU (�yc1 S Cit � �,,l,t, � ZIP� S'��i� <br /> Contact Person: �,�,.� Applicant is: Contractor / vHomeowner (Circle One) <br /> Email and/or Fax: °(��}--. �-��-C>`JS S "r�Jv�n,�rnv,�� Cow� <br /> ,� <br /> PROPERTY OWNER INFO MATION: <br /> Name: S��e� (,�'U �e� (�e� <br /> Phone (day): <br /> Address: �� �� Cit : ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal & <br /> �[New Constructio�G��'dU Sin le Famil with Water Supply <br /> � g y ❑ Residence <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) ,2. ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> "Any earth movement may require ❑ Commercial �Other(spe ify) <br /> MCWD review&permits. ❑ Industrial �c�2e�� ❑ 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) $ aU� S�JZ� — <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />