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t <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> _— -_, Mailing Address: p�0/( —Dfj55'cf � <br /> %"��,�j�� PO Box 66 Permit number: <br /> /r � <br /> �i0 , Crystal Bay, MN 55323-0066 Date received: 6`Z�—�� <br /> ��` /�,� <br /> ' �� Received b �iC�J� <br /> �I <br /> � <br /> ���a ��"��� .�� ,.;� Street Address' Y� <br /> �����,, ���,�y�,����� 2750 Kelley Parkway Plan review fee: 303. 39 �6�� <br /> �RgEsi�o�`'j Orono, MN 55356 ������0 c�3 b�yl��( <br /> — � Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us ��J <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: -�-�--5 -�� <br /> Job Site Address: �� � � �,�r"� � �� ��,c�(r ,'_ r-¢jrC /'-��! <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 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/APPLI ANT INFORMATION: <br /> Name: �� � aq pK� <br /> State License# ����- <br /> Phone: �� 4i/�(o 2-Z cl � (office) �S� ���= ; `t�� �,1� �G-L (cell) <br /> Mailing Address: ; z � r�,1 L � s-T Cit :L. a <,- L�9- r ZIP: .s�.s-�_s— <br /> Contact Person: �_.� f'v�y�K F Applicant is: Contractor / omeowner �c�r�ie one� <br /> Email and/or Fax: T�� n�r;�F � TC c TF�� S-/j��-f- c c� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �l��l'K� /�I v4-,�� G—�-,f`r T J�141�Kt' <br /> Phone (day): �S�2 9 z s� 3 �'?�; <br /> Address: � y 2 c� ���,- j ���- � T City: L �,�,r( L�q.n�ZlP:s���� <br /> Email and/or Fax �'��.� ,���������-��-��E��s-���1- C� �, <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: ��-/9��f� <�- i1'�S c�l /°� �i�= r <br /> Phone (day): ��� - �l7 s� -�� v � - w'� <br /> Address: 1� � o N'� ,('Ty ��2r�..,,.,,C z,� S-� City: S'��i�/L Fy ZIP:�� �� <br /> Email and/or Fax: _ � S� za 7S- g'z �� <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 �] 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) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Nni✓w.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �c�� � c o ,. �, L <br /> _ <br />