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t <br /> City of Orono <br /> Building Permit Application pu,�, <br /> for New Structures or Additions �3�9•z� <br /> Mailing Address: Permit number: :�100 3-f�0`�/ � <br /> �.��,�. PO Box 66 <br /> � �1 , 0 <br /> Crystal Bay, MN 55323-0066 Date received: 7/(c� 'd <br /> '�'�JR� ' �, Street Address:� Receiv e d b : <br /> ��l "�'�����'�`��v�~� Oro�no, MN 5356 ay Plan review fee: , E;,�j/ <br /> 9kEsH04'� �J��C1��13 <br /> ��__-" Total Fee: <br /> Main: 952-249-4600 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:� �� � , ��,�,��, 6'� , �'S � ( � <br /> Job Site Address: <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 approva160 days prior to the event. Shuttle bus servi will <br /> required unless applicant demonstretes su/ficient on-site parking is available. Non-permitted events will not be allowed. <br /> __._----- <br /> CONTRACT /APPLICANT IN ORMATION: f ,� / <br /> Name: �----.. . �� � lM �C �.e.--l.X� c.ii� lti.>'"'� <br /> State License# Expiration Date: Cp! Z 3v 6 y SS <br /> Phone: S 2 �'� (� Y O (office) ! Z �y � 3 `7� (cell) <br /> Mailing Address: n�-�2n�: .2�.� Ci : � �.�c� �j <br /> Contact Person: To � C� I l✓�^-, Applicant is: Contractor Home wner Circle One) <br /> Email and/or Fax: d✓t N G� C_�,i.� s" � L_,�-i r-� <br /> PROPERTY OWNER INFORMATION: / I r � <br /> Name: I o�� � 1/� � � l�-e_l� �'Z � �� �"-�� <br /> Phone (day): (.F (2 � � � 3`1 ( <br /> Address: -'7 k /li . �/L�.�.� N--�t' ��" City: c�F� �1 � ZIP: � SS��1 I <br /> Email and/or Fax /Y]��v��ci�vi S E�' �G�-� l.�>�2� <br /> ARCHITECT I ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <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 attached garage �Garage Accessory Bld� ❑ Public Sewer <br /> cessory Building ❑ Single Family with Deck <br /> ❑ Relocation detached garage ❑Office/Commercial ❑ Private Sewer <br /> �Other. (specify) '�d� ��'�"��`✓ ❑Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑Storage ❑Public Water <br /> '*Any earth movement may require ❑Commercial �Other(speafy) <br /> MCWD review 8�permits. ❑ Industrial o b l ���l� ��„ ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) Other: (speCify) � � <br /> 18202 Minnetonka Blvd ,�� 'pY-1,�i�GL.= - <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ��--{� O�O ,v O <br /> Last Updated: 6/22/2009 �-L-�� <br /> - 19 - <br />