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. ' City of Orono <br /> Building Permit Application <br /> for New Structures or IQ►dditions <br /> Mailing Address: ��� ` <br /> �A, PO Box 66 Permit number: <br /> � f vQ Crystal Bay, MN 55323-0066 Date received: �7 <br /> Street Address:' Received by: <br /> � ,� 2750 Kelley Parkw � J��j� Plan review fee: <br /> F �` Orono, MN 55356 �5 2 2 • <br /> lqkES H��� Ma in: 952-259-4600 <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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � <<y L <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes o <br /> /f yes,a special event permit is required with Po/ice Department and City Council approva/60 days prior to the event. Shutt/e bus service will 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: (�DvA�vc�� 44�.rhF xre z.; S SN <br /> State License# 3G (2��(oc, � Expiration Date: 3/3i j�p <br /> Phone: (cell) -�� �c���S .r�' (office) �/5� S I� F51 S� <br /> Mailing Address: , .,p � ��� � 6 7 City: ���T�. ZIP: 3� I <br /> Contact Person: �. � t,. Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �j�,-�, y�°�,-- � S-� <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ A��rvc�s� i-h�m s �,�TE.z� ��i �r+ C• <br /> Phone (day): �7�, c�qc� � �-3�; <br /> Address: l� 6/ �„���-Z,a,..,,� � b�� �� f �F ►��7 City� c.���2,a—�4 ZIP� 5� 3y� <br /> Email and/or Fax o�d.��,r,�c.�t-,��..-.�+��;,,,���� � L„� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: �'j��+2 �p� � v-t.u► <br /> Phone (day): G)5�., 7 y���a � <br /> Address: City: ZIP� <br /> Email and/or Fax: C�ga _ �y(p_ -7-�Jo'� N/111�CE'� ,o [�FrIfZ p�'�q�-;rv��,�„� �g���� <br /> L o r� <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8� <br /> Water Supply <br /> � dew Construction �ingle Family with ❑Accessory Bldg./Garage <br /> ❑Addition attached garage �Deck �ublic Sewer <br /> ❑Accessory Building ❑ Single Family with [� Office/Commercial <br /> ❑ Relocation detached garage �Residence <br /> ❑ Other: (specify) ❑ Private Sewer <br /> ❑ Multiple Family/Condo Retaining Wall(s) <br /> ❑ Public 4-feet or greater �ublic Water <br /> **Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review 8 permits. ❑ Industrial ❑Warehouse ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (Specify) ❑ Other(SpeCify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka, MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.m innehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ 3 S � � (J�'�' � <br /> Packet Last Updated: January 2015 <br /> Page 20 <br />