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, City of Orono <br /> ����c�in Permit i4 lication Gl - �� <br /> � pp � `-t-� <br /> for �ev�c ��r�ctu�es or �dditions <br /> Mailing Address: C��,_G.�' � / <br /> QA� PO Box 66 Permit number: � <br /> � j V� Crystal Bay, MN 55323-0066 � Date received: S c� —� So <br /> StreetAddress:' � ��� Received by: <br /> '' ,� 2750 Kelley Parkway ( I <br /> y�'�q ��` Orono, MN 55356 v �U( � Plan review fee: 3�.`j.?j <br /> kESHO� Main: 952-249-4600 Total Fee: ���'�� S�-s <br /> 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. (P/ease print) <br /> GENERAL INFORMATION: �� � , , `,� <br /> Job Site Address: �/ �� '=n. - �,,__,,�' �..Y� <br /> Wi�l this be a Parade of Homes, Remodelers �Sho case Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is required with Police Departmen7and 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/APPLICAN INFORM TION: <br /> Name: -' � ti 1�`� �I�L- : <br /> State License # Expiration Date: - <br /> Phone: cell - U ffice <br /> Mailing Address: ` � !� G Cit : �p; ' <br /> Contact Person: ` Applicant is: n acto / Homeowner (Circle One) <br /> Email and/or Fax: � ' � • - <br /> PROPERTY OWNER IN ORMATION: <br /> Name: / .c.c�t� � � , ZI l0 {0(�'ic.0 CaVtQr� 1_�,UZl,t �5�� <br /> Phone (day): -1 <br /> Address: ' ��'P�z-� i ,• Cit : Z�P: <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER�VF�OR. M�TION: <br /> Name: �=-�L�'� <br /> Phone (day): <br /> Address: Cit : Z�p; <br /> Email and/or Fax: .Q(' o (aarc,.(.�►'V1 <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: G-�� � <br /> Phone (day): � ' <br /> Address: Cit : Z�P. <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal & <br /> 0 New Construction in le Famil with 1Nater Supply <br /> g y ❑ Accessory Bldg./Garage <br /> ` ddition attached garage ❑ Deck �] Public Sewer <br /> ccessory Building ❑ Sin le Famil with <br /> g y ❑ Office/Commercial <br /> ❑ Relocation detached garage Residence e tic <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retainin Wall s P <br /> � 9 ( ) (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 ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify) ❑ Othe�(SpeCify) <br /> 15�20 Minnetonka Blvd; Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ �� , <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />