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��,�� <br /> � City of Orono �" <br /> ��.�����r�� �Qr���; �������t.��+� <br /> for New Structures or Additians <br /> -_ _ _ <br /> Maitinc�Address- •� <br /> "'�y� P��OX� �'C 1?t!i� Ilt!!IIfIC'!: v(���(,� (., <br /> /;� � -�V <br /> �����` Ctystal 8ay, MN 553�3-t� Date received: ��Z.p f U� <br /> � � :�, <br /> �� �' '�I Received by� � � <br /> ,� �� ��� �,;, Street Rti�f�ess:' <br /> ��,�;.��-�' !�,,�G�,- 2750 Kelley Paric��raY I'tan revie�✓r tee: --'� <br /> ����'��'Esia��`-�. Otono, MN 55355 - - <br /> _...- Tot�! Fr,r,: 9�// p� <br /> Main: 952-249-4600 Fax: J52-249-4616 !,�`l(�,�0 <br /> _ __---- _ - __ __—_ __. _ -._ _. <br /> This applic.�tion f�rm must t�e c.om�teted in full and atl rec�uired inform�si�n m«st hP suhmitted. <br /> incomplete applications wiil be retumed. (P/ease print) <br /> GENERAL INFORMATlON: � <br /> Job �i#e Address: �Z�17 �<�.f�z•r� �b r� � ���� Qt'-���� V���_ <br /> Wili this be a Narade of Homes, Hemodelers Showcase Home or other Uisplay Home'? (J Yes (X[No <br /> ff yes a special ererrt�r�emiit is rec�uired witY�Poiice DepaRment and City Courrcif approvaf fi0 days prior to the event Shuttle bus service will be <br /> /t;4JiiU"u Ulii�;u F:�j.ti�e:u/ei(ic.�li�v(�Sir�:iG�S S(1(i�uu(ii Oi�-:�iie>�a(riiiy is�vaiJuult. i�fuir-�ti�iiiitd�'ve>!ds i�'iii Iivi LB�sfiu�hr"tii. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �4�.t:� —�t�:�c,�c�C� _ --- - -- <br /> State License# -� �cpiration Uate: '� <br /> Phone: ^\Z- $\Z- 1�\�� �o�} �1\Z-�,�Z-1�\� (�11} <br /> Mailing Address: z v �x✓- � �s N _ �Ciiy. �.� {P: �S�(�� <br /> Gontact F'ersan: „�""�.���� /:p�E� nt is: Gar�tractar / I�amea•�rner �c�«ie.o�,e> <br /> Email and/or Fax: � 5�- �.�-1Z _ <��<� d,� \ � � <br /> � C�,-�r.:o.Zc� o.� ��ss����Q-_ �'�u__ <br /> PROPERTY U�NN�R 9NFORPAATiON: <br /> Name: Sc�;rne.. c`;,� C'���.-�� _ <br /> Phone (day): <br /> Address: City: ZIF': <br /> �rnail and/or�ax <br /> -- ----- -- --- _ __ _ _ <br /> ARCHITECT/ENGlNE�� lNFORM.'�TlON: .--._._._.__� --�� <br /> Name: �)��t�b.v..w�2- -- �v� D�vY� <br /> Phone (day): (� S`- �S�— 3(�,\O ` \ <br /> Address: -a� � .,t o � �e�`�- C=ite�e.. City: S�"���v.� ZIP: SS (Z� <br /> Emai! and/or Fax: �� �'S�_ 4,-7�a.�' <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3. Sttucture Type 4. Sewage Disposal& <br /> Water Supply <br /> ❑ New Construcbon ❑ �ir�yle�"ar�iily v✓itli ❑ f2Lsiuer�ce <br /> ❑Addition attached garage �Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Builc�ng � Single Family with Deck <br /> ❑ Relocatian ` detached garage LJ 4fficelCommeraak [J Private Sewer <br /> �,Utt�er. (speciiy)�2-�c?.�c. .�rL (J tJiulG�le Fa�nily/Gondo ❑VJatePEouse <br /> '�.,,� - ❑ Public ❑ Storage ❑ Public Water <br /> ""Any earth movement may require ❑Commercial ❑ Other(specify) <br /> MCWD review,&permits. ❑ Inciustrial ❑ Private Well <br /> Minneh2ha Cre�l:L�l�aterst��iJistric�(M(:1t1s�1) '�}Uthe�: (spec�fy} <br /> 18202 Minnetonka BNd , ��� <br /> Deephaven,MN 55391 `V <br /> F�hone: �2-471-U5� <br /> Far': 9G2�71 �8? <br /> � www.minnehahacreek.orq ( _L_ __ - <br /> Estimated Construction Valuation (excluding la�) ; � ,�� <br /> - 18 - <br />