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City of Orono a���� le <br /> Building Permit Appfication <br /> for a Swimming Pool ,�a�3°� <br /> �_--� Mailing Address: <br /> �—-� Permit number: D-�Ofl��. <br /> �,�.� PO Box 66 <br /> � Crystal Bay, MN 55323-0066 Date received: 8 /O <br /> , � �:� � ;, <br /> ���''�"`� i Received b Q <br /> ,� � �,�,�' �, ; Street Address: Y' <br /> �'.c, � 'z �HO,. Gti � 2750 Kelley Parkway Plan review fee: /72. S� 0?0/0-00 /( `,Q� <br /> L��`���g,� Orono, MN 55356 <br /> \kEsxo� <br /> --/ <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: �� I � ������I f�., -�� � <br /> CONTRACTOR/A fjLICANT INFORMATI01"q� I <br /> Name: .�� S �-z, � .� "ti C � =\ � <br /> State License# ��j Expiration Date: �' ( <br /> Phone: _ _ � - 5 - Fax: Z - �` � � - . �- � �� <br /> Address: � "� � � ; ,� --�,`; �� Cit : ;,,�• ZIP: <br /> Contact Person: '� c�v`v�c:� ContacYs phone number _ <br /> Email n - �` oc� 5���p�icant is: Contractor Homeowner (Circle One) <br /> PROPERTY OWNE�INF�RMAT�ION: � <br /> Name: �� -� �"V'� r <br /> Phone(day): � <br /> Mailing Address: i��� �'-�v ✓� c:-_ � � � . ZIP: r�_-S � � <br /> Email and/or Fax <br /> ENGINEER INFORMATION: <br /> Name: <br /> Phone: <br /> Address: City: ZIP: <br /> Email Fax: <br /> PROJECT INFORMATION: <br /> 1. Pool Dimensions: 3.Accessory to: 4. Pool Type: 5. Sewage Disposal 8 <br /> ❑ Above ground Water Supply <br /> � � � �Single Family n-ground ❑ Public Sewer <br /> �(�X .� feet ❑ Multiple Family/Condo <br /> ❑ Public ❑ Other(specify) ❑ Private Sewer <br /> 2.Heated? <br /> ❑ Commercial Excavated materials will be: ❑ Public Water <br /> �yes ❑ Industrial <br /> removed from site ❑ Private Well <br /> ❑ no ❑ Other: (specify) <br /> ❑ used on site <br /> ❑ Other: (specify) <br /> � r <br /> Estimated Construction Valuation $ �� ���--� <br /> Last Updated: 9/1/2010 <br /> - 7 - <br />