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09/29/2010 10:36 TEL 6512920905 f�001/002 <br /> ` ���� �� - �C �� �. <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> `- Mailing Address: �� <br /> - 0 � <br /> / �, .�� PO Box 66 Permit number: (�/�_��7� <br /> �!�0 0�;,, Crystal Bay, MN 55323-0066 Date received: ' / <br /> ��:':�T� I <br /> �� ,�� r��::=;: �.I StreetAddress:' Received by: <br /> � � p'y"�,�, p�`�) 2750 Kelley Parkway <br /> t ' '�'" `� Orono, MN 55356 Plan review fee: <br /> 9kE5H0�'/ ��j <br /> Total Fee: x"��� ��r <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: ��'� � -s-�.�.��,`; '�.�; ������ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes .��o <br /> If yes,a specia!event permit is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service wiU be` <br /> required unless applicant demonstrates suffrcient on-site parking is available. fVon-permitted events wil!not be allowed. <br /> CONTRACTOR/APPI�ICANT NFOR TI p�V <br /> Name: � 1 `� r <br /> State License# +G �^ Expiration Date: � ,2 <br /> Phone: - - - � ����:> office 57- ' (�,-- y� i% cell <br /> Mailing Address: "�,� �„�:.�.� �}�e_t�-. City� 5 ��s ZIP� ' �,717 <br /> Contact Person: � � w� Applicant is: n ra t'S / Homeowner <br /> Email and/or Fax: �� �� 7 (Circle One) � <br /> ' c�; C�iK <br /> o _ <br /> PROPERTY OWNER INFORMATION: ° <br /> Name: .�, ��, <br /> Phone(day): �'� --��r,� �u <br /> Address: V �y`�'; � �� Cit : ,v� ZIP: ��,���� <br /> Email and/or Fax <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 /> Water Supply <br /> ❑New Construction �Single Family with '�iesidence <br /> ❑Addition attached garage ❑ Gara e/Accesso Bld <br /> ❑Accessory Building ❑ Single Family with ❑ Deckg ry 9� ❑ Public Sewer <br /> ❑Relocation detached garage ❑ Office/Commercial <br /> her: (specify) `r ❑Multi le Famil /Condo ❑ Private Sewer <br /> P Y ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial <br /> ❑ 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 G'V� ` D <br /> Fax: 952-471-0682 Q(/t <br /> wvvw.minnehahacreek.or �� <br /> Estimated Construction Valuation (excluding land) $ � <br /> Last Updated: 9/29/20�9 <br /> - 17 - �� <br />