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<br /> ,
<br /> City of Orono
<br /> Building Permit A lication ����°
<br /> pp �
<br /> for New Structures or Additions
<br /> Mailing Address: permit number: z�/ 3
<br /> A, PO Box 66
<br /> / � 'v� Crystal Bay, MN 55323-0066 Date received: "�J' --I r -1 l�
<br /> I � Street Address:' Received by: � �
<br /> _ _. __--
<br /> �� ;l 2750 Kelley Park y����..��'r p�an review fee:
<br /> � c, Orono, MN 55356 T
<br /> /`�Kf 5 H O�� Main: 952-249-4600 Tota
<br /> Fax: 952-249-4616 ,,+:-;,,,• ,,,, r,r�.us
<br /> This application form must be completed in full and�alt required information must be su mitted.
<br /> Incomplete appllcations will be returnsd. (Please print) � �
<br /> GENERAL INFORMATION: � � �, � �G,
<br /> Job Site Address: � .z�r- '� yJ � "� � ��
<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 prio�to the event. Shuttle bus service ilf be
<br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: rj;'�'rrF} _ �crw�e-S ��: ,
<br /> State License# �G�ic,^}y I 2 f.� Expiration Date: 3 31 �e�g
<br /> Phone: (cell) � � Z �-!'T G� -- �-'`► ��- (office) (, 1 Z ��n - �-"►j«
<br /> Mailing Address: '� (,,,%� �� �{-►�.L � Ci :�. ,�� e� ZIP: �,�'"p �+�'
<br /> Contact Person: Applicant is: ontrac or / Homeowner �c��ae o��
<br /> Email and/or Fax: *,� - S � , �..z,�.�
<br /> PROPERTY OWNER NFORMATION: r�
<br /> Name: ��-�'Y/� �ri'f� N�-- � ��.,�-N"f"1.� �rni c-,c�(
<br /> Phone (day): �j� - � �t �—y� -�
<br /> Address: ;�?5','' rz¢,r-�'4�► i n/�;�, ��Si- City ���-7�.JD ZIP• �/,��p
<br /> Email and/or Fax =----
<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: �-�� �"��cc' T� ''`- '.
<br /> Phone(day): .y� '7$�, _ ' ��,
<br /> Address: :�. ,_ �„2. � Ci : .1, � ���ZIP: s ��3 �-
<br /> Email and/or Fax: _��z�=' ,�,�„�,�Z„� p.}-j-, �,.��;
<br /> PROJECT INFORMATION: Descri tion of ro'ect:
<br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8
<br /> Water Supply
<br /> ❑ New Construction ❑Single Family with ❑Accessory Bldg./Garage
<br /> ❑Addition attached garage ❑ Deck ❑Public Sewer
<br /> ❑Accessory Building ❑ Single Family with ❑O�ce/Commercial
<br /> ❑Relocation detached garage ❑Residence ❑ Private Sewer
<br /> �Other:(specify) oC�C�t?n �G1v ❑Multiple Family/Condo ❑Retaining Wall(s)
<br /> �`'rpt ❑ Public 4-feet or greater ❑Public Water
<br /> **Any earth movement may require ❑Commercial ❑Storage
<br /> MCWD review�permits. ❑Industrial ❑Warehouse ❑ Private Well
<br /> Minnehaha Creek Watershed District(MCWD) �Other:(speCify) ❑OtheY(SpeCify)
<br /> 15320 Minnetonka Blvd
<br /> Minnetonka,MN 55345
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
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<br /> S �, :� .�
<br /> Estimated Construction Valuation (excluding land) I �
<br /> �LS t� ��.!�"D U�".1_ E��l s`�r ..o` S-T�����S I L�J�i Z �fiv� ;'I�C�L.��
<br /> U Q �
<br /> Packet Last Updated: August 2015 � O� ZO G
<br /> Page 21 }� � �
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