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City of Orono � <br /> Building Permit Application '��' <br /> D�� <br /> for New Structures or Additions <br /> Mailing Address: Permit number: Q/ -�(' <br /> �Q A>O PO Box 66 <br /> `V Crystal Bay, MN 55323-0066 Date received: �-'��l l.s <br /> Street Address:' I / Received by: /�� <br /> -` 2750 Kelley Parkwa �I�✓ g <br /> ti�, �' �I� � Plan review fee: <br /> C. Orono, MN 55356 <br /> `qKfSHO�� Main: 952-259-4600 l Total Fee: ���`5-�� <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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: .•?-,,�� �� r->.r�� �� •— <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f 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 sufficienF on-site parking is availa6le. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: -����s'-=-�r� l__=.;Zy`� <br /> State License# ?-�,�� - ��,c;� Expiration Date: `��j�_„�-��,^ <br /> Phone: {�;��(cell) �1 -Z?„�; . �.��.� (office) I-__>^/ _ �C��:-� �� � <br /> Mailing Address: — � . Cit : `--. {}�.,�_. ZIP: .�_ <br /> Contact Person: ����_�_�������, Applicant is: ontractor �/ Homeowner (Circle One) <br /> Email and/or Fax: _ ' � �� ?.._ �-�`�_�,r� t� � -��� �-.:� <br /> PROPERTY OWNER INFORMATION: <br /> N a m e: �•-�.c�v��-�� � G`��.-E.t�=-� <br /> Phone (day): �r;�- �j��- �h� <br /> Address: •�,cc -�� �y�r,.�,�^�1 '��C City� �.c.t� ZIP� -�' <br /> Email and/or Fax y � r <br /> ARCHITECT/ENGINEER�NFORNJA��: <br /> Name: �l� <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> r--(�,.c�i�-+-����.:�.>�...�:�.�s.�i�.x;k=.5� CY'z�= �-E���� <br /> PROJECT INFORMATION: Description of proje :i�-i� t Zx c� „�°..�a. �'3..t._ ��. i,.�j-��_'� <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction �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 esidence ❑ Private Sewer <br /> f�Other: (specify) c�r�;- i�,C� ❑ 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) ❑ Othef(Sp2Cify) <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) $ ' '�-�r�-��. <br /> Packet Last Updated: January 2015 <br /> Page 20 <br />