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�ity of �ror�Q <br /> �c��[e�i�� �err�it Applicati�r� <br /> � � far �e�nr ����ct�res or �ddit�o�s <br /> Mailing Address: <br /> Q�T PO Box 66 Permit number: � — � (`�� <br /> � j YQ Crystai Bay, MN 55323-0066 Date received: � ?�� �(� <br /> Street Address:' cEjv�d by_ /� <br /> y � 2750 Kelley Pa ay 4 - t '� �`L� p�an review fee: I �'� <br /> �' � Orono, MN 5535 Z d�10 -Q((� � /�� - <br /> t'�k�sxo�`` Main: 952-249-4600 otal Fee: <br /> Fax: 952-249-4616 vw✓w.ci.orono.mn.us <br /> Tt�is.app�ication fiorm must be completed in full and aPf rec�uired information must be submitted. <br /> Incomplete appllcations wiN be returned. (P/ease print) <br /> GENERAL tNFORNfATION: <br /> Job Site Address: ���-{ ' _ �; Z��Q <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home. Yes No <br /> If yes, a specia/event permit is required with Police Depa�finent and City Council approva160 days prior to the evenf. Shuttle bus service will be <br /> required unless applicant demonstrafes sufficient on-sHe parking is available. Non permitfed events wil/not be allowed. <br /> CONTRACTOR/APPLIC NT INFO MATION: <br /> Name: b/c.ar,� � �c- �'� . ��v ��s L'!._ <br /> State License # �'3G U,r�-� ���, Expiration Date: ; • Zp�c�, <br /> Phone: cell �,,�a- � _ office <br /> Mailing Address: '+-�. `'� Z�� ' Cit : ,� ZIP: �53Q,�� <br /> Contact Person: � � - Applicant is: o tracto / Homeowner (Circle One) <br /> Email and/or Fax: o,sc� �;��,�,.� �, ��cl'�� ,,�m <br /> ` <br /> PROPERTY OWNER INFORMATION: <br /> Name: �.,-;:�,�� c�r,� ��r3r� .> ��r�i s��r� <br /> Phone (day): _ � p� <br /> Address: !P�JI�i ��-�,_, �� �� City. . ;�-�-���� ZIP `j`�� I <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: <br /> Email and/or Fax: Z�P <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: Ci ; <br /> Email and/or Fax: Z�P <br /> PROJECT INFORMATIO�I: Description of pro'ect: �ii ��1�� C� `��5 �.J.-� � <br /> 1.Type of Project 2.Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Construction �+,Sin le Famil with Water&upply <br /> 1� 9 y ❑ Accessory Bldg./Garage <br /> ❑Addition attached garage � Deck <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial � Public Sewer <br /> �Relocation detached garage ❑ Residence ❑ Septic <br /> Other.(specify) p.E=�xrrQ (�3r� � Multiple Family 1 Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> *'Any earth movement may require ❑ Commercial ❑ Storage <br /> MCVIID review 8� permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑ Othe�(SpeCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehahacreek.oen <br /> Estimated Construction Valuation (excluding land) $ �2 � <br /> Packet Last Updated: January 2016 <br /> Paae 21 <br />