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\� <br /> \ <br /> t <br /> t ' <br /> City of Orono <br /> Building Permit Application ,� <br /> for New Structures or Additions � ° ��, 7�' <br /> Maifing Address: � aB�� -�Q 7 7 t� <br /> ���,�� PO Box 66 Permit number: <br /> �/� �: Q�\ Crystal Bay, MN 55323-0066 Date received: 8 ,30 /O <br /> � �'s��-� I <br /> I ���; ;r �� Received by: <br /> ,a �� -,s-�:;� s, Street Address:' <br /> �'�,n � �'(,r�,� ���� 2750 Kelley Parkway Plan review fee: D/O'd D 77� <br /> '�9.kEs�� Orono, MN 55356 �77 � <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: p � �}; o �, N /� �S J�jC� <br /> Will this be a Parade of Homes, Remodelers Showcase Ho e or other isplay Home? ❑ Yes No <br /> If yes, a special event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wi be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI ANT INFORMATION: <br /> Name: SM� ��:���trS L��i <br /> State License# _pq,�b Expiration Date: �f����o�� <br /> Phone: office cell <br /> Mailing Address: �, Cit � ZIP: S 3 <br /> Contact Person: Applicant is: ontracto / Homeowner (Circle One� <br /> Email and/or Fax: M�vS�,r" �J i••►Sv+.C,oM <br /> PROPERTY OWNER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: _ City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: -}� <br /> Phone (day): gs -y - <br /> Address: <j S • p Cit : ' ZIP: S � <br /> Email and/or Fax: 9SZ- y70- � 0'7 <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal & <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence <br /> Addition attached garage ,�Garage/Accessory Bldg. ❑ Public Sewer <br /> Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private 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 ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) � h r: (specify) <br /> 18202 Minnetonka Blvd (;� oV� '}0 4 <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ p <br /> Last Updated: 9l29/2009 <br /> - 17 - <br />