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7 �� <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> _� Mailing Address: �Q� _�O� 4/ <br /> ;�g,D,j�\ PO Box 66 Permit number: �� <br /> '�Q , �� Crystal Bay, MN 55323-0066 Date received: � �/ / <br /> `�a �y�'�-: a,!� Street Address:' R e c e i v e d b y: <br /> `\�'�t�;�j��;�, ��� 2750 Kelley Parkway Plan review f e: <br /> ��gESHo�'%� Orono, MN 55356 <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 appfications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: ��L� �j��r•�r,,, �� 1,1 ��� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes, a specral event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will e <br /> required unless applicant demonstrates sufficient on-site parkrng rs available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Li�tK� ��l�-�S <br /> State License# � � N �� <br /> yn ����,r�j� ` Expiration Date: <br /> Phone: (912-�{� - � 03�-- (office) (cell) <br /> Mailing Address: u3 ��n-��2��� uJ��.,, City: iDbQi�r ZIP: " �,� � <br /> Contact Person: GLr1�ne,, tZv'�o..� Applicant is: Contracto (Circle One) <br /> Email and/or Fax: rVl iY�,Q�(1t- G o� ,C�i„� <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ , ,o�nv�e � �o�,.i��. 2u�A� <br /> Phone (day): �-���(�-�-Ly I$- <br /> Address: 33�� C�,RA�-!�� ��� ��� Cit : OCUn� ZIP: SS35(o <br /> Email and/or Fax �o�n�in� , r"u w �Ma� l.cs�� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: Cit : ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal & <br /> ❑ New Construction Water Supply <br /> ❑ Single Family with ❑ Residence <br /> ❑ Addition attached garage ❑ Gara e/Accesso Bld <br /> ❑ Accesso Buildin 9 �Y 9• ❑ Public Sewer <br /> rY 9 ❑ Single Family with ❑ Deck <br /> ❑ Relocation �! detached garage ❑ Office/Commercial <br /> ❑ Private Sewer <br /> Other:(specify) rl R � � '�` ❑ Muitiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> *"Any earth movement may require ❑ Commercial ,�Other(sPecify) ov.{'� <br /> MCWD review& permits. ❑ Industrial �'1RC.�W��p���n+�i1 �Private Well <br /> Minnehaha Creek Watershed District(MCWD) �Other: (specify) �T <br /> 18202 Minnetonka Blvd �,�,Own� d��y <br /> Deephaven,MN 55391 1 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.m innehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ p�-� <br />