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�ity o� �rono <br /> ��i�c�i�� �erm�t Applicatfo� ,� <br /> f��- �'�rr� ����ct�res or i4d 't�o�s �� �� <br /> Mailing Address: <br /> �Q� PO Box 66 ; Permit number: ( � � ��; �, <br /> � Crystal Bay, MN 55323-0066 �' ,�' Date received: �j �j� <br /> � <br /> StreetAddress:' - _�,� -� �' Received by: �' � <br /> y� ,� 2750 Kelley Pa ay �., i � �` z�� Plan review fee: � �'� <br /> �, Orono, MN 5535 . � ���C� - C;(�� � �J�_`-------- <br /> _._..__. <br /> '�kfSH��� Main: 952-249-4600 -fiotal Fee: <br /> Fax: 952-249-4616 www.ci.orono.mn.us <br /> Tk�i�application form must be completed in fuli and af( required information must be submitted. <br /> Incomplete appifcations will be returnec�. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �r�� ' � ��, �;, 2�1�� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home. ❑ Yes ❑ No <br /> lf yes,a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLIC NT INFO IVIATION: <br /> Name: Vc.,�,� , ' -��• .��, ��r�.� H� L.9.-_ ' <br /> State License # a3C ����� a2�. Expiration Date: %; � , Zp ic�; <br /> Phone: cell (�g�- , -�, _ office <br /> Mailing Address: 'y' ��'- 'Zy'1`� - Cit : ZIP: `j53g��, <br /> Contact Person: ;��iL -i H�. � Applicant is: o tracto / �Homeowner <br /> Email and/or Fax: �� �^ (Circle One) <br /> CS `c�i n r�n �y C�Y��C'1�1� ��rr� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �:�--,:-Y,�•; r�� S�ra.� v ��r�� •v►�,�r <br /> Phone (day): � _ - _ �r-y <br /> Address: 1�`���� f=�-.,T:r�-� k� . �2.1 City: �:�<-• y� ZIP� �j�j3�i i <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: Z�p• <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: Z�p• <br /> Email and/or Fax: <br /> , ;` . ; �. <br /> l _,-- , <br /> PROJECT INFORMATION: Description of project: ��� �-��` � ��� ` �����=> �- � ��:� , (�' �<- <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal 8� <br /> ❑ New Construction Sin le Famil with �Nater Supply <br /> ❑Addition � 9 y ❑ Accessory Bldg./Garage <br /> attached garage � Deck ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial ' <br /> �Relocation detached garage ❑ Residence ❑ Septic <br /> Other.(specify) p.E=�¢�� �=� � ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> "'Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review�permits. ❑ Industrial ❑Warehouse <br /> ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify) ❑ Other(SpeCify) <br /> 15320 Minnetonka Blvd; Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> wv✓w.m i n n e h a h a creek ara <br /> Estimated Construction Valuation (excluding land) $ /2 � <br /> Packef Last Updafed: January 2016 <br /> Page 21 <br />