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' City of Orono <br /> � Building Permit Application <br /> for New Structures or Additions <br /> >— Mailing Address Permit number: <br /> :g,0,�.�> PO Box 66 <br /> - 0 :. � <br /> Crystal Bay. MN 55323-0066 Date received: <br /> �� • Received by: <br /> a l��r�µ ' ,, ' StreetAddress <br /> 'f�, �,��S�A;�';� G� 2750 Kelley Parkway r Plan review fee �� <br /> ty�Esxos``'�v Orono, MN 55356 P� lO�1�J <br /> � -- � Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 �r���lv; ci o+onamn us <br /> This application form must be comp�eted in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ;;�7C�C� P`'l//T L- ��'t� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �-fC�o <br /> If yes. a special event permif is required with Police Department and City Council approval 60 days prior to the event Shuttle bus service wifl be <br /> required unless applicant demonstrates sufficient on-site parking is available Non-permitted events will not be allo�ved <br /> CONTRACTORlAPPLICANTINFORMAT�ON: <br /> Name: /�!'<7'+�Nlr-/�' �li'=�r'�;'"sr� L�G C <br /> State License# �� ; �',�y��� Expiration Date: �- :�Q��l <br /> Phone: �_-,/�--�yjL3 - c.�y y 7 (office) --- (ceU�}--- <br /> Mailing Address �?sy.�,;l. !5��= �''/4'%t�' City: ��,,r���-• ZIP: _,5� 7�f <br /> Contact Person: j,7�T �, ��,,,�`;,.� Applicant is: �E�iii[� r a/ Homeowner (CircleOne) <br /> Email and/or Fax: QS;2— �;�3-9 ��,�,• <br /> PROPERTY OWNER INFORMATION•. <br /> Name: �-t�:'; �%��t'1'i9/��� , <br /> Phone (day): _���,a —(U 7t�`? �- Y-�� S{ <br /> Address: /Ui� L�•.i/vt_.r (s'•r��� �, v�' City: ��i'v/i c.'1 ZIP: _��_S.�3 j_ �. <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFO ATION: <br /> Name: <br /> Phone (day): <br /> Address: Cit : 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 8�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 /> wwev.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ jQ, ��C'�� <br /> Last Updated. 6/22/2009 <br /> - 19 - <br />