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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: <br /> �g,�,j����� PO Box 66 <br /> /�0 � �\A\ Crystal Bay, MN 55323-0066 Date received: <br /> /I ""`�` 1 I <br /> � Received b <br /> ( a �� �?�s;�� �, Street Address:� Y� '�-i� <br /> �'.� �� �;'",�� �� 2750 Kelley Parkway Plan review fee: <br /> t�k��H�og,� Orono, MN 55356 <br /> �-- <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: 02� /'1'� ��Q,�.� <br /> Will this be a Parade of Homes, Remodele`rs`Showcase Home or other Display Home? ❑ Yes �] No <br /> !f 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: j<_,.�_a�,- ���� `-'r�--�i��:.� <br /> State License# ��.��-� � I ��-�<--- Expiration Date: <br /> Phone: , -Z �� ,, �� �� � I � (office) '_] (y ; `�T '�-�� � �O�; (cell) <br /> Mailing Address: �' , ��� c� L�� � Cit : _; , ZIP: r-s;�-� <br /> Contact Person: _`�r>� � ���_- Applicant is: _ontract / Homeowner (CircleOne) <br /> Email and/or Fax: � � <br /> PROPERTY OWNER INFORMATION: <br /> Name: � .� �,� M�.�e:>A�� <br /> Phone (day): �'� 7_ ���i Z,�7 � <br /> Address: Z� �- �y�+vU� City: 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 Construction Water Supply <br /> ❑ Single Family with ❑ Residence <br /> ❑ Addition attached garage ❑ Gara e/Accesso Bld <br /> ❑ Accesso Buildin 9 rY 9• ❑ Public Sewer <br /> ry g ❑ 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 <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Private Well <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) $ � �r�.��_,r� <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />