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. <br /> ' City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: � <br /> (� PO Box 66 Permit number: 2(�(Ip�Q(�� �` <br /> � � Crystal Bay, MN 55323-0066 <br /> 0 Date received: �!�—� `7—/ (o <br /> SfreetAddress:' --� ��l�'�s'��..��-'. - 4 ' <br /> y ,�' 2750 Kelley Parkwa ��(p'�C� p�an review fee: <br /> �' c? Orono,MN 55356 2 � �, � 3 <br /> t�kfSHO��' Main: 952-249-4600 � e. �____-- <br /> Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in fuil and ail required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �y�3 �-}- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> li yes,a specia/event permit is required with Police Department and City Council approvaf 60 days prior to the event. Shutt/e bus service will be <br /> requir�d unless applicant demonstrates sufficient on-site parlvng is available. Non-permitted events will not 6e allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �i'�-/`v S (Q C.�-.• u,,. <br /> State License# (�yS�1 y Expiration Date: � � �'7 <br /> Phone: cell �1- 3 - �/� office <br /> Mailing Address: 3q 7 .,1,►� ��e, �/ Ci : Rubb��+s a,le ZtP: SSy22 <br /> Contact Person: �� Applicant is: on ra / Homeowner �c���o�e� <br /> Email and/or Fax: �,s� �c n,-L�� a�e���oeh�rc, rv� <br /> PROPERTY OWNER INFORMATION: <br /> Name: � cY.,� (���fil.� <br /> Phone (day): 9 SZ.-'��iD-�1'i9 lo <br /> Address: '1. 13 C.ur w�cx-, �` Ci : p,r,�-•,� ZIP: SS 3� 1 <br /> Email and/or Fax ��}y��hv�-rv��.i .W,,,,e <br /> ARCHITECT/ENGINE INFORMATI N: <br /> Name: v�- i�1d 'Qrct,�}jn� SQ('vj�eS <br /> Phone(day): �5�-�4S`t-"L�oS <br /> Address: v w �+� S Ci : M�n ��i s ZIP: S S y 10 <br /> Email andlor Fax: W; I . �,. ;P I d �o,,,�a;�,[,.,,�•� <br /> PROJECT INFORMATION: Descri tion of ro'ect: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> ❑New Construction Water Supply <br /> ❑Single Family with ❑Accessory Bldg.!Garage <br /> �Addition attached garage ❑Deck �Public Sewer <br /> Accessory Building �Single Family with ❑Office/Commercial <br /> ❑Relocation detached garage ]�Residence <br /> ❑Private Sewer <br /> ❑Other: (specify) ❑Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑Public 4-feet or greater � Public Water <br /> **Any earth movement may require ❑Commercial ❑Storage <br /> MCWD review 8 permits. ❑ Industrial ❑Warehouse ❑Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑Other:(speCify) ❑Othef(speCify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation(excluding land) $ �S 2� a c�c�, � <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />