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f +9522494616 T-657 P.001/005 F-658
<br /> Jui-21-�`09 10;02am From-CITY OF ORONO
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<br /> City of Orono
<br /> Building Permit Appfication
<br /> fiar New Strucfiures or Addifiior�s
<br /> O Mail;ng Address: ' Permit number: Q�UILnCe P�Gx
<br /> � � P4 Box 66 I � d oy�
<br /> 0 0 Crystal Bay, MN 55323-0066 i Data recaived:
<br /> a .
<br /> �:..
<br /> '.;�� c. StraetAddross:' Received by: �
<br /> ��� ' ' �� 20750 Ket`l�ley Parkway �jC1�V•' Plan review fee: /, 7s
<br /> g�s�o�. rono, N 5.,356
<br /> I Total Fae�._ ��y1�
<br /> Main' 952-249�600 Fax: 952,249-4616 www.c;.orono,mn.us ,
<br /> 7his app{ication form rrcust be completed in fUll and all req,�ired information must be submitted.
<br /> Incomplete appfications wil! be returned. (Please prinf) 7�2��0�J
<br /> GENERAL MFORMATION; � k.��'"� � ,
<br /> Job Site Address: - �. : ,
<br /> Will this be a Parade of �mes, Remodelers Showcase Home or other Dispiay Hoir�e? Yes [� No
<br /> If yes, a speciel evant permtf is required wrrh Polic�Deperrmenr and Clry CounCil epp�ov81 60 d&ys prior fa th�9vHnt. Shuttle pus serviCe wi11 b6
<br /> tequired unlesa appGc&nt demonstretes Sufficient on-si[o parking is availabl9, Non-permitrsd evenfs will noi be ellaWetl,
<br /> CO►YTRACTOR/APPLICAN� 1NFORMATION:
<br /> Name: A!I . �� i•� u�. S� �-,�� r'S �'.��;o-
<br /> State License# Expiration C�ate:
<br /> Phon�: - 'S�j � ` (ofFice - ' - - r�'�r (celf)
<br /> Mailing Address: � --t 3.,�,�' r c� Cii � �.:::,�:�alc� ZIP: �
<br /> .. . �_ �,r .?
<br /> Contact Person: • � ,., � -.- - , � Applicant is; ontractor % Homeowner �c;�c�eoRa�
<br /> Ernail and/or Fax: �=.,v � - �,,, . .., �-.- _„ , ' �„ ' _ �{S � �',r'
<br /> 4 �
<br /> PROP�RTY OWNE�t INFORMATION: � ,,_� ;�
<br /> me; �.�?,� ,�,�r,��_� d�v. �.- � ��..� �, ��'t> .�f-� -.i ..., � t -.� ���
<br /> Phone (day): ��-�,_,�,_S��—L�.�`{ ' � � .�. 'L �a:
<br /> Address: _ 4 City• Z1P:
<br /> Emai! and/or Fax _ ;�->�,�-� �r�s.„��;F c,�-.�1�� . c �f.v�
<br /> ARCNITECT/ENGfNE�R {NF�RMAYI�t�t:
<br /> Name: ,��r,�:s�.��.L 1��e�i,� 1�-Pc`��, ��a,.., �,�r .;✓�
<br /> Phone (day)� c�,�,:� - �s'-�_ "� �'i��� -
<br /> Address: o'S e�.� �: a� t�- ,f ��.� �"�.f City: �!w y��� `-�'�,. Zlr�; �� S c,�"�' �
<br /> Emailand/orFax: •�-�.rr v�' �.v ���nr� �r"-r��,f� , C ci;� ��.
<br /> � �
<br /> PROJECT lNFORMATION:
<br /> i1.Type of Project 2. Proposed Use i 3.Structure Type 4. Sawage Disposal& '
<br /> ❑ New Constructi�n [] Sing1E-amily witr '� ❑ Residence I W$ter Suppty �
<br /> ❑ Addition attachad gafege � � Garage/A�cessory Rfd�. � ,.�� Pubfic Sewer j
<br /> � ❑ Accessory Building ; [j SinglE =amiiy with ! � Deck '
<br /> ❑ Relocation ' � detached ara e I
<br /> 9 g ❑ Office/Commercial I rl ?rivafe Sewer
<br /> � '��, Other; (specify) �� ���-w,r��` ���'Dt ❑ Multi le Famil /Condc
<br /> �• P Y i ❑Warehouse �
<br /> ❑ Pubiic I ❑ Storage !,�I Public Water j
<br /> i "Any earth movoment may require � � Commerciai 1,-' Other (specify)
<br /> � MCWD r�view& permits. ! ❑ Industrial I ❑ Private Wei!
<br /> Minnehaha Creak Watershed District(MCWD) i ❑ Other. (Sp2Cify) �
<br /> 18202 Minnetonka Slvd �
<br /> Daephav�n, MN 55381 I
<br /> � Phone� 952-471-0590
<br /> Fax� 952-Q79-0652 � f j
<br /> www.minnehahacreeK.or I �. � �
<br /> Estirnated Construction Valuation (excluding land) � / � � �%
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