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City of Orono ��
<br /> . . . . f �'�3 •
<br /> Building Permit Application �
<br /> for New Structures or Additions
<br /> Mailing Address: ri ` '
<br /> /f �O A' Permit number. �� i�;�'��'�'�
<br /> PO Box 66
<br /> ; �VQ Crystal Bay, MN 55323-0066 Date received: �/'� � 7—I (c:
<br /> �� � StreetAddress:' � - __ _. _. .R�c_eivedh�.--__ 4�. �
<br /> ,;� � ,� 2750 Kelley Parkwa r� i (�'Lb�9 ' _ _____._ --�
<br /> j\�,q,� ��` Orono,MN 55356 �. 2�� � �, �.� _� P�an review fee: _ , ' G ,
<br /> � � _ � _
<br /> _�___
<br /> �F s�i o Main: 952-249-4600 _ - -
<br /> __._.
<br /> _. . e: �
<br /> Fax: 952-249-4616 �v�n�w ci.orono.mn.us �
<br /> This application form must be completed in full and all required information must be subm ed.
<br /> Incomplete applications will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �y�� r �, - „ ;-}�
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No
<br /> !f yes,a specia/event permit is required with Police Deparfinent and City Council approva160 days prior to the event. Shutt/e bus service will be
<br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be al/owed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: F��r�U `�-}+ I� U:... .z,,,,
<br /> State License# �.�y,?1 y Expiration Date: 3 � 7
<br /> Phone: ce�l �;1— ,� - o[<�, office
<br /> Mailing Address: ��� -7 ���,_ �j�,n�. �/ Ci : Rub�����s �,1�= ZIP: �1 r/z2
<br /> Contact Person: ;.�;�, N Applicant is: ocC n�raZ,`t�o / Homeowner �c���o�e>
<br /> Email and/or Fax: �,.;t.� !J�;,.,�L, ���c,.,���<r�,fr+, ,c,u„�,
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: `?�},�_� ►�\�,��,,
<br /> Phone (daY): `�5 i . ;�c�— 1`i�l,
<br /> Address: Z�t�3 c.�,rww-, ��- Ciry: �r.a ZIP: S�.i� 1
<br /> Email and/or Fax �}-�,,����,�- .,.,
<br /> ARCHITECT/ENGINE INFORMATI N:
<br /> Name: t��-���1�1 '()Y'���'���-, ��rv�c,eS
<br /> Phone (day): `j 5 L�-4 S`t--Z�v 5
<br /> Address: ^�c� w u+�� S Cit : /�^�r✓�,su �I�� ZIP: �>'--I 1�
<br /> Email and/or Fax: �1" I ; �;;- a���� cr��,,,,��,,;j,�,;,rr
<br /> r! l.., f� I/
<br /> PROJECT INFORMATION: Descri tion of ro'ect: t�C'j ��C� V�- l""C�r i c�� �IGC,� � ��C�� /Z ��(`�
<br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& �
<br /> Water Supply nl
<br /> ❑ New Construction ❑Single Family with ❑Accessory Bldg.!Garage f [ � '
<br /> [�Addition attached garage ❑ Deck �Public Sewer
<br /> C�Accessory Building � Single Family with ❑Office/Commercial
<br /> ❑Relocation detached garage �Residence ❑ 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&permits. ❑ Industrial ❑Warehouse ❑Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑Other:(SpeCify) ❑Other(SpeClfy)
<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 `�-,, ��v. "`�
<br /> Packet Last Updated: August 2015
<br /> Page 21
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