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� <br /> City of Orono 5, �� <br /> Building Permit Application <br /> � �� <br /> for New Structures or Additions <br /> Mailing Address: Permit number: a0�a - ��� / <br /> Og,�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: �d' -/ � <br /> � � ,��, �, Street Address:� Received by: 0���- � <br /> ,�, �ti`S' 2750 Kelley Parkway Plan review fee: ��� -b /� � <br /> L9kE3H��`� Orono, MN 55356 1C�3, � � <br /> Total Fee: �J <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us '" ��f � I � <br /> This application form must be completed in full and all required information must b ubmitted. `� .3; -��, <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 2 lo`f� �x s-r �r'o�� , .^-�� S53`�/ <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 approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: City: ZIP: <br /> Contact Person: Applicant is: Contractor / Homeowner (Circle One) <br /> Erriail and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: -j�Yc�.,-cA S fQ, (���5'2�N� <br /> Phone (day): ��z —s�Z_ �� <br /> Address: ���{a -�k 5�— City: ��^pN b ZIP: �53 `�( <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION:/I <br /> N a m e: �'�Orr yo S t1'• ��S��nrr' �C�ia/�€� � c�CJ�5TL1 N-4 ��3—�YZ---`;�3`��_ <br /> Phone (day): ` '�_S " Z— 1 , O c7 � ' <br /> 9 ! <br /> Address: Z �`fC� o -r Cit : /�o�,t� ZIP: �j3 �; <br /> Email and/or Fax: _�,�/ �-?z,� y' . Lb.�.L <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence <br /> ❑Addition attached garage �Garage/Accessory Bldg. ❑ Public Sewer <br /> "�Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> "*Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �J 0 Oo�_� <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />