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� � � _ <br /> 1 �, <br /> P ���;� ��,,., U� � � � <br /> , .� �� �� �� <br /> City of Orono <br /> � / <br /> Building Permit Application <br /> for New Structures or Additions <br /> �-- Mailing Address: Permit number: o�((�j�- ��g e <br /> �.��,j�.O PO Box 66 <br /> Crystal Bay,MN 55323-0066 Date received: <br /> � �� ;�" a, Street Address:' Received by: � ���Q/ O <br /> ,F, �ti 2750 Kelley Paricway Plan review fee: ss/• $9 <br /> l9x�xog� Orono, MN 55356 �p� g -Op $�� <br /> �_- Totat 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 retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ,-�","f S /'�I�i'1�I� �i� N. GtJa(j�tu�a�, /t�t N 63�g � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay ome? ❑ Yes No <br /> If yes,a specia/event permit is required with Police Department and City Counci/approva/60 days prior to the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: (�.vial,, �S¢t� S <br /> State License# ,�d J�,s'��f Expiration Date: ✓Nc�'G _o'J�/O___ ____ <br /> Phone: - 7 office `1 - d- cell <br /> Mailing Address: Y1'1 U � Cit : ZIP: ,S` <br /> Contact Person: Applicant is: ontractor / Homeowner �c�r�ie o�� <br /> Email and/or Fax: , i . �Q�'v� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �o�j � {l�w�, �2�FF�iv <br /> _- -- _ __ _ _ __ _ <br /> Phone(day): q 5a- y 7�- a�� 3 <br /> Address: /2 G►��v v C�k�,4-sc City: Gur�ZctT�,�- ZIP: �.S3�j � <br /> Email and/or Fax K.�n. �R�� �:v �� 5 � Ino Ae_. Cow� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: j��Tt fZ., C 5 I�u c,�'E <br /> Phone(day): (Q 1 a- �4� — 75 75 <br /> Address: City: ZI P: <br /> Email and/or Fax: =.w�fl @� E 5 k�c.�F. • Lo w� <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 ❑O�ce/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:(Speafy) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-d71-0682 <br /> www.m innehahacreek.o <br /> Estimated Construction Valuation(excluding land) $ a.9�A/1 <br /> Last Updated: 9/29/2009 <br /> - 17- <br />