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� t �� � � �� <br /> � <br /> City of Orono <br /> Building Permit Application �, <br /> for New Structures or Additions �Sg� �s <br /> Mailing Address: i <br /> �,L,�,�p\ PO Box 66 Permit number: �4/O —D � �9' 7 <br /> /Q :\ Q Crystal Bay, MN 55323-0066 Date received: g Zy /Q <br /> 1 5 rk� � <br /> � <br /> �I a f�'"���;'� s,�! Street Address:' Received by: <br /> � i.,:� <br /> \�'� ��M�� o~% 2750 Kelley Parkway Plan review fee: <br /> ��� ��� Orono, MN 55356 /759.3�1 <br /> xESHo aoio -oo8qlo <br /> Total Fee: <br /> Main: 952-249-4600 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: /��5 fa��,,,.� ,s Po,�-- ►:�w� <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/APPLICANT INFORMATION: <br /> Name: w�c�.ltiar� C�all�.�� Ca,,,s�E. T� � <br /> State License# d.�o L�'.S6 Expiration Date: 3 3� z o r z <br /> Phone: �,z-�c q-9�9 (office � ��z- 7v y-i�9� cell <br /> Mailing Address: a �k ,,c Cit : Qeja w� ZIP: ss 3z� <br /> Contact Person: �«�,.� ��lk s Applicant is: ontra / Homeowner (Circle One) <br /> Email and/or Fax: �_�,a►��s @�cl,5; . «�,,, <br /> PROPERTY OWNER INFORMATION: <br /> Name: �0.-�-��- t3r�•9 q s <br /> Phone (day): �31a -- `Jo��g 9 <br /> Address: l4ll 5��0) +{��sr ��.� City:�kk �$�rbarK C�ZIP: 93sa� <br /> Email and/or Fax <br /> ARCHITECT I ENGINEER INFORMATION: <br /> Name: `�as.:., .�c�tt s��., <br /> Phone (day): 7 b 3 - zZ 5 - 55 <br /> Address: �;a� � „�qy�s �r;,,e City: I„�2„c��y ZIP: SS 3�� <br /> Email and/or Fax: �;,,,,, ����__�_ ���� y���� «-,.- <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) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ 375�` ��, <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />