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� <br /> �� \� � <br /> Ci of Orono � � 31 ' � `� <br /> tY / <br /> Building Permit Application <br /> for New Structures or Additions <br /> /-=0-� MaifrPgO Bd�drss�s: Permit number. O` —0 d <br /> �''� �':. <br /> /�� Q\ Crystal Bay, MN 55323-0066 Date received: _ <br /> , �� s �', <br /> Received b <br /> !'�a '��,��:;�__ a��i Street Address:' Y� p <br /> `��',�, �'�,�-_��"��� G��` 2750 Kelley Parkway Plan review fee: (p�, O <br /> \�����o¢jG' Orono, MN 55356 �p��_�/O� <br /> ,_ <br /> _._._. <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 <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: �a�" �Y„�C��Q� �d . N. <br /> Will this be a Parade of Homes, Remode(ers Showcase Home or other Dispfay Home? ❑ Yes �No <br /> If yes,a special event permit is required wrth Police Department and City Council approva160 days pnor to fhe event. Shuttle bus service will be <br /> required unless applicant demonstrates suffidenf on-site parking is available_ Non-permitted events wi/t not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: I�adou� � � �ldiv� <br /> State License# �pg-�3Lnp►-� Expiration Date: '3 � <br /> Phone: (�1a -��b-aatsa office cell <br /> Mailing Address: � e N � Cit :1�,�,�{� ZIP: 553► <br /> Contact Person: Na�.¢._ 'T�vr�nv� Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: t1�u.r-vv�a�rraa�l��.��w:1di��G . C�w� ���c: 3�0�`��3-515� <br /> � - <br /> PROPERTY OWNER INFORMATION: <br /> Name: Yh�k�J �2V S9ux.�C� <br /> Phone (day): q�,2 �'f�4 - '7`Jy3 <br /> Address: 'jJS �,me�d..�.Q IZd � , City: �Q1r�4'1.� ZIP: S53`�/ <br /> Email and/or Fax �iv�;k�o�. SpWadct.�.Ow� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: �1� �C�i��3-�- �.��� �?�--�i Q� <br /> Phone (day): �� � $�O - lc� <br /> Address: \0135 �"I�`�` /�V� N • City: Q(��pv� 1-� ziP: 5 Sy�/�2 <br /> Email and/or Fax: Y"S�r�i��n� c.pYY�CQ, ,t�j,Q�- <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 ttached garage �.C'arage/Accessory Bldg. ❑Public Sewer <br /> ��ccessory Building ❑ Single Family with ❑Deck <br /> . ❑ Relocation detached garage ❑Office/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�71-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �j��0O0 <br /> Last Updated: 4/26/2011 <br /> - 19- <br />