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, <br /> City of Orono <br /> Building Permit Application ,�d � � 7� <br /> for New Structures or Additions � <br /> Mailing Address: Permit number: oZO�I IJ�/D� <br /> �j,0,�.� PO Box 66 ' <br /> O O� Crystal Bay, MN 55323-0066 � r, ;` Date received: a /S !l <br /> `�.° ��. �� i � I`..' ° <br /> I �,,� � � �. � �, ��� Received by: <br /> a ,� �, I StreetAddress:' I � <br /> ,� � :,�,�-� �, � J, ` '4, <br /> ,F, � �9_ �� 2750 Kelley Parkway v Plan review fee: p2Dl/��D��� <br /> y�� <br /> �`�kEsxo4`'� Orono, MN 55356 �� ��� �g <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: <br /> Job Site Address: ���C�'C- Ft,; S �r 'f' <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 w�ll be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION• <br /> Name: � � �:. <br /> State License# Expiration Date: �Z� <br /> Phone: ' � � ' �3 office �'_ - cell <br /> Mailing Address3 Cit :' ZIP: � , <br /> Contact Person: Applicant is: �ontracto / Homeowner (Circle One) <br /> Email and/or Fax: c� ` <br /> PROPERTY OWNERt INFORMATION: <br /> Name: l.V'`c���c�.,.-� l ru��l� <br /> Phone (day): `�SZ�. �t�3 ' ,�l'�.� lvk��Z <br /> Address: 3"3UC: �o� S-}-- City: �cv��, ��c.� ZIP: SS '�S� <br /> Email and/or Fax �j��..= 4�`�, � Z� �"��j —� <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: � � M ��i�� _ <br /> Phone (day): `�' L 2 �'�''�3 <br /> Address: y� 330�. (x�ti�.�.. �I'P� City:S�-L,;,;,;5 pc..�I�ZIP: ��Z {G�— <br /> Email and/or Fax: � ' 2 rc, c,; �S� . C �^^ : <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 Bldg. ❑ Public Sewer <br /> ,0'Accessory Building ❑ Single Family with ❑ Deck <br /> Q`Relocation detached garage ❑ Office/Commercial rivate 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 �rivate Well <br /> Minnehaha Creek Watershed District(MCWD) �Othe�: (speCify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 / �� <br /> Phone: 952-471-0590 (.-/�'�'f'5���"�� �� <br /> Fax: 952-471-0682 �u`c���C <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �f�, ; , <br /> Last Updated: 12/21/2010 <br /> - 19 - <br />