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y <br /> � <br /> l./ �•���0 <br /> � <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions '� 03�•S� <br /> Mailing Address: permit number: D l6—O� 7�'� <br /> O�,�,�.0 PO Box 66 B <br /> Crystal Bay,MN 55323-0066 Date received: <br /> Received by: �� <br /> ,a -;%� �, Street Address:� �/z D � g <br /> �'�, � � G~ 2750 Kelley Parkway Plan reviewfee: Z ,� <br /> lyx.�Hog,� Orono,MN 55356 CO/IiCG� q/i • o� �7,80 <br /> __ = Total Fee: <br /> Main: 952-249-460Q Fax: 952-249-4616 www.ci.orono.mn.us �D/0—d07�T <br /> This application form must be completed in full and alt required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ' ",� J-���t�.ilf ,U��l. /L'� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes,a specia!event permit is required with Police Department and Cify Council approval 60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates s�cient on-site parking is available. Non-permitted events wiN not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 7PatCl(i Cu�:�/Y►iL lf� � . <br /> State License# O Expiration Date: � ,3/ 20/ % <br /> Phone: c - 7 -�� •� office �.�1 -v"z`f:��s,� � cell <br /> Mailing Address: :3� Cit : ZIP: <br /> Contact Person: °(i rl, �1 Ap�licant is: ontracto�! Homeowner (Circle One) <br /> Email and/or Fax: � - �✓ �•,�� � � . /v�E'[, /. �ir✓1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: �j l (,�/��n <br /> Phone(day): Z - � � Uz Z <br /> Address: lZj C�&� S D�• City: ����1/���� ZIP: .5.��?`� f <br /> Email and/or Fax tC/;�G2�F6/..,1[,� � Z'�,�� C6iY1 � <br /> ARCHITECT/ENGINEER INFOR�IATION: � <br /> Name: �'�.�t.(C�l't� GI��I�c� (p/�Gl�� <br /> Phone(day): (p � � - ���� �-' ,l�-7 S <br /> Address: ��1 y -�r, �fX.✓t �'c/: t1r" . City: �'1't 7';E"ck ZIP: ��-3��.,5- <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structu�e 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:(Specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.m in nehahacreek.or <br /> Estimated Construction Valuation (excluding land) S �/.��..�ri <br /> � — <br /> Last Updated: 9/29/2009 <br /> - 17- <br />