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City of Orono 18 <br /> Building Permit Application #oq ,,?� <br /> for New Structures or Additions <br /> Mailing Address: <br /> Q PO Box 66 Permit number: (✓/(7/-0/ 3 .._2)�i Crystal Bay, MN 55323-0066 Date received: /��2�.-�/t� <br /> Street Address:' Received by: jZ(� _ <br /> - 2750 Kelley Parkway ci ,� <br /> itiliL <br /> y� Plan review fee: 1/ 7.7") <br /> c` Orono, MN 55356 / / ` i�QOtj <br /> 1kes H o0' Main: 952-259-4600 ee: <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: (0Z5 FE/JD/el-Le- Ae /IV /)O 7+ <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: Led" &t? T --i25 x1/4 14,t Rzt3701ro-Vez-<oz- <br /> State License# ,03 G-3 Z5 5' Expiration Date: 3/3t //6,Phone: (selyDiawT 952--`7%-37 S 3 (office) 45"2- ?4,4y- q 4 99 <br /> Mailing Address: /50 l'2, 117&Efumie 117 Cit :A etvatrej <44 ZIP: 3 '5• <br /> Contact Person: 44 f1,C Itl#F,1.141 Applicant is: Contr. • / Homeowner (circle one) <br /> Email and/or Fax: AitKE/'4.47ts9)4L r'/3.e6S C J4li?x' qc -9'/2 -le, - ' <br /> PROPERTY OWNER INFORMATION: <br /> Name: CAR,S Uri) A,r.O p64--g e L! Er11 (9 IA -' ' <br /> Phone (day): 7(23- 22l— 4 //it rokieso4) <br /> Address: 62.5' > viR,e7 ) 7 -f City:0 -7 y q- ZIP: $s.5/ <br /> Email and/or Fax c#9-1Q50AJ r 4.41)6 ailizcgi lL.L ,C-On4 <br /> ARCHITECT/ENGINEER/INFORMATION: <br /> Name: A)l - <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project:I:4400a- b1TT/Witovt,--(.3d2n2cesdr WP&s, 'aceu <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& 3e0 <br /> Water Supply 1,04/166- <br /> El <br /> 9r?/2❑ New Construction ®Single Family withResidence L <br /> Addition attached garage 0 y�y <br /> Garage/Accessory Bldg. ❑ Public Sewer <br /> u Accessory Building 0 Single Family with 0 Deck <br /> ❑ Relocation detached garage ❑Office/Commercial X Private Sewer <br /> igi Other: (specify) I AJ ❑ Multiple Family/Condo ❑Warehouse <br /> 0 Public 0 Storage 0 Public Water <br /> "Any earth movement may require 0 Commercial 0 Other(specify) <br /> MCWD review&permits. 0 Industrial ,i Private Well <br /> Minnehaha Creek Watershed District(MCWD) 0 Other:(specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ 2 SO/ co.-) <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />