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� �J� � <br /> � � <br /> � City of Orono <br /> Building Permit Application �.� <br /> for New Structures or Additions <br /> � i ��� <br /> Mailing Address: Permit number: 1-L�� - r`C C � 7 <br /> �,0,�. PO Box 66 <br /> Q �a\ � ,\ Crystal Bay, MN 55323-0066 Date received: J 1 <br /> �`��'�� Received by: � � C���(��i'� ��'�-' <br /> ,� I�ti��-`� ,, Street Address:' <br /> �'�, � ��C���. �� 2750 Kelley Parkway -t1,���( -(�`b3�. Plan review fee: � , (� 'v g� <br /> r�ESHo�`,� Orono, MN 55356 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us O5 <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: � ( ,,,� � �, �r <br /> Will this be a Parade of Homes, Remod lers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service ill be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permrtted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: I <br /> Name: !�c,rlL D. .,•) � .; �;�..5 CuSt�+�-� �'t�w�es : v, C <br /> State License # �a•i q �w o �� Expiration Date: <br /> Phone: C�I,}.-�sl —`� >�� (office) (cell) <br /> Mailing Address: 9.�� . �o x S- + Cit : �,, r <.,},�, ZIP: S� �t i <br /> Contact Person: Vy��rl� ti� ,\\; �-w. S Applicant is:�Confrac r� / Homeowner (CircleOne) <br /> Email and/or Fax: -'�ct ,�?' 11 ; �w�s I�.�v,,,�s c�' ��,L�c•c� ��w, __.__ - <br /> PROPERTY OWNER INFORMATION: <br /> Name: C �r;S iVl� (��� �^ <br /> Phone (day): �/Sd- �S� - a?a � <br /> Address: �/,--� ��„F L��; rt,,,�,se r,�� . City: �►^� �v ziP: S�3�, L <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 /> Water Supply <br /> ❑ New Construction � Single Family with ❑ 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) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> *"Any earth movement may require ❑ Commercial '�Other(specify) <br /> MCWD review& permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (Specify) p <br /> 18202 Minnetonka Blvd ��`�1 �S ����c`�� <br /> Deephaven, MN 55391 % ��� ,S�fc,� <br /> Phone: 952-471-0590 'r <br /> Fax: 952-471-0682 �'"� �ln�G��cc� <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ����. �•ov, `'" <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />