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- City af Orono <br /> Buiiding �err�it Appiicatian <br /> for (�ew Structures or Additions <br /> �O A T MailiPO Bo�r66� Permit number. _�� . ...� Q <br /> !VQ Crystal Bay, MN 55323-0066 Date received: 7 Z , , <br /> Street Address:' Received by: �� <br /> � ,� 2750 Kelley Parkway � - <br /> y�'� �� Orono, MN 55356 �� "'f� �P�����^'fee: , 2Q <br /> '�xESHO� Main: 952-249-4600 otal Fee: <br /> 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 �� ��� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No <br /> /f yes, a special event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shutt/e bus service wil/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: Gr� '��,`,!�„� �-, Bt,v H��-- <br /> State License# —' Expiration Date: <br /> Phone: �cell) �/�_ $5� � 9�f � (office) <br /> Mailing Address: .�,,� �� �t,r Cit : <br /> Contact Person: Applicant is: Contractor / meowner <br /> (Circle One) <br /> Email and/or Fax: 1�'�. ,r�,`�a.,` �p�,.,,•/f�,`,f.y ,y e�c�..,��� ca,,..,., <br /> —� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��.�s�1 � <br /> Phone(day): <br /> Address: City: ZIP• <br /> Email and/or Fax <br /> ARCHITECT 1 ENGINEER INFORMATI,Q N: <br /> Name: /�'j.c �`i� .4����r-Sa�-- <br /> Phone(day): �/�_ �l� �p <br /> Address: Cit : ZIP: <br /> Email and/or Fax: M /��,, ,�,,. Sa.� 73� �fraa�' . L'd� <br /> ARCHITECT/ ENGI ER INFOR ATION: <br /> Name: �� '�h � �, <br /> Phone (day): �/� ,�y��� <br /> Address: Cit : ZIP: <br /> Email and/or Fax: _ �d �" 103�/� av •�� <br /> PROJECT INFORMATION: Description of project: ��"���� � <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Construction Water Supply <br /> �Single Family with ❑Accessory Bldg./Garage <br /> �Addition attached garage ❑ Deck �$(Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage �'Residence ❑ Septic <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wa►I(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> ""`Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) � pthef:(SpeCify) ❑ Other(SpeCify) <br /> 15320 Minnetonka Blvd; Minnetonka, MN 55345 �Pfivate Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ j�a �, <br /> Packet Last Updated: January 2016 <br /> Paoe 21 <br />