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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> �..-- Mailing Address: <br /> �� ��� PO Box 66 Permit number: -QQ � <br /> � � � � Crystal Bay, MN 55323-0066 Date received: ` � <br /> ( �� � Received by: <br /> ,� �t� '� �,) Street Address:' c� <br /> �.�, � �`����� �ti� 2750 Kelley Parkway Plan review fee: � ��� 8/ <br /> ���g�s�g,�i� Orono, MN 55356 � a � �. ���Q <br /> �_—_� <br /> T�tal Fee: /D <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 8a,1, �� <br /> This application form must be completed in full and all required information must be s bmitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: . <br /> Job Site Address: 5 �it,��, <br /> Will this be a Parade of omes, Remodelers Showcase Home or other Display Home? Yes ❑ No <br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates suffcient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/A PLICANT�N FORMATION: <br /> Name: 1{1�(u,�s Cy1� �, <br /> State License# 20 Expiration Date: ,� •3 f •Zof 0 <br /> Phone: 2� Z• 1 0 office cell <br /> Mailing Address: O 0 � Cit : rya�7T ZIP: �5 +��-- <br /> Contact Person: Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: p„� a� e . torvt, <br /> PROPERTY OWNER NFORMATION: <br /> Name: ��,�,� �� (�, <br /> Phone (day): (�i2-�S32•47`� <br /> Address: 0 3'`-�� - Cit : � mJt�T ZIP: -`�5�� �" <br /> Email and/or Fax : �. <br /> ARCHITECT/ ENGINEER INFORMATION: j <br /> Name: Gi�py�S �vj�,Z� f,�,.Sp�6Q <br /> Phone (day): (�12•332•'�7q7 <br /> Address: � Cit : �yA1UJ'T ZIP: G�� � <br /> Email and/or Fax: �o � � !� V , ��,�,� <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8� <br /> Water Supply <br /> �lew 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) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ _fT�9J � g�e <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />