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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: permit number: <br /> ��A rO PO Box 66 <br /> `w C stal Ba , MN 55323-0066 <br /> rY Y Date received: c� <br /> � SfreetAddress:' ved b : <br /> � y ,� 2750 Kelley Parkway C/L ��� Plan review fee: <br /> F c.� Orono, MN 55356 � 20�b ' <br /> t'�k�SHo��' Main: 952-249-4600 Total Fee: <br /> 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: 18$Cj ����d�o. �_ Dro.10 , m �.1 5534 <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 Counci!approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates su�cient on-site parking is avaifable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: ohl�'t' (ir4t l�dm2S �'n.c.• <br /> State License# $c. e�o N4 Expiration Date: D 31 Zo� <br /> Phone: (cell) letZ.-�q�-�22l0 (o�ce) 4�2-�q� -12.7�10 <br /> Mailing Address: �Ev 2"� S�-• Su r�Y �' ��l Cit : �%tGls rb� ZIP: gS3S� <br /> Contact Person: (Zo� �`�eoycn Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: r�pt�G�$Gr1(fl tD �r++A.1 1 . C.o� <br /> PROPERTY OWNER INFORMATION: • , <br /> Name: Ca�o►y,� $ , �t�r �1r,Q,�d j�, lta.�5c,r- <br /> Phone {day): (o►Z- l.l d- S�o Z <br /> Address ZQ5_S� Q�ov�1a�c...e. �1q.�4. City: S�lepr.,d,�rc�,ZIP: 553$� <br /> Email and/or Fax C 1�(4,«.r ."7 ��r,�,�l-wn �'aa-d • Go•�+-� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: �jha,�rQc�'4' Ar��9n � Co+�►�ci��1 <br /> Phone (day): q5 Z' �"to' 9"f 50 <br /> Address: �},IoH Z^ S} sw� e i� Id0 City ��,Qls�r ZIP� w��.1 <br /> Email and/or Fax: Ko�roSS� S►'►a.�r4"H'del�i jv+ • Go� <br /> PROJECT INFORMATION: Description of pro'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 ❑ OfficelCommercial <br /> ❑ Relocation detached garage � Residence ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall{s) <br /> ❑ 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) ❑ Othef(SpeCify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) � � � Zd� � 0 00 � d p <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />