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D <br /> ����� ' <br /> � City of Orono <br /> � Buii in � <br /> d g Permit Application ��,� <br /> for New Structures or Additions <br /> Mailing Address: � � � }� ���� <br /> O�(,L,O,�O PO Box 66 Permit number: <br /> � Crystal Bay, MN 55323-0066 Date received: � � d <br /> Q��`,�- Received by: <br /> � � s. StreetAddress:' <br /> ..�„�a <br /> �'� �'�'.� �~ 2750 Kelley Parkway Plan review fee: ��j •Z � <br /> t�kESH�4'� Orono, MN 55356 <br /> Total Fee: a��� �/� � / <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and ail required information must be submitted. <br /> Incomplete applications wili be returned. (Please prrnt) <br /> GENERAL INFORMATION: <br /> Job Site Address: � � �d ��c�s� E�f <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <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 sufficient on-srte parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI�INFORMATION: <br /> Name: /„�j/qiY' <br /> State License# Expiration Date: <br /> Phone: 2/f�-3¢3 - 6gS� (office) (celi) <br /> Mailing Address: o D��is �tve E7rf Cit : S n Rw% S'S �- <br /> Contact Person: App(icant is: Contractor I (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INF R ATION: <br /> Name: �� g�9'/Y <br /> Phone (day): 2 (g -3¢3.�gSS <br /> Address: � Oo ��'�.�rs�vr E� City: S��^} ��'/� ZIP: S S 3 $� <br /> Email and/or Fax q�(A�,�6(q,r C� 9��' � � <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 8� <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence <br /> ❑ Addition attached garage '�`6�rage/Accessory Bidg. ❑ Public Sewer <br /> �Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multipie Famity/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> `"Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ fndustrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ,�Other: (specify) <br /> 18202 Minnetonka Blvd i S'far�� w��� �Q✓¢� qr(a �`f"x �¢' <br /> Deephaven, MN 55391 �si►� ¢x,s,yt� ��p.,n/, <br /> Phone: 952-471-0590 ���d� � ���,�d <br /> Fax: 952-471-0682 �M 6� <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ p0 �-� <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />