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, City of Orono <br /> ' � Building Permit Application <br /> for New Structures or Additions <br /> ,—� Mailing Address: Permit number: p� ��� '���„3� <br /> y O�O CrysBtal Bay, MN 55323-0066 Date received: � �%�3 / f/ <br /> � �� <br /> ,� -�' �, Street Address:� Recei : L-C� <br /> �,�, Gti 2750 Kelley Parkway �()f I 'CC�37S Plan review fee: � oZLJ .��I <br /> 't•9kESHo4� Orono,MN 55356 <br /> `�, <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 retumed. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �1 F�'r�,r_ �� r.'�'v •�f � <br /> Will this be a Parade of Homes, Remodelers Show ase Home or other Display Home? ❑ Yes No <br /> If yes, a special event permit is required wrth Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: >'1/1;�=ti�,;u s�-�� � �; � ��,s,.-;fs'v��;r� L L G <br /> State License# �O 5 7 �331 Expiration Date: � � <br /> Phone: - y -g ' office �C�;}' - '' - $/(1 cell <br /> Mailing Address: �� �;a�,�,,,. 7rr.�,` CitY� G rr�:-,�Je�r� ZIP: �'�'_3S�7 <br /> Contact Person: j�,��,( � ;�//o` Applicant is: n ractor / Homeowner (CircleOne) <br /> Email and/or Fax: rh S T(' C � f�<<�,nr� Gn;/Y► <br /> PROPERTY OWNER INFORMATION: ,/ <br /> Name: L�Pfi�v�t�° ua�r.� :,1^'��1 ; �;�.y'1 I�o.v i r � <br /> Phone (daY): F,f�- ��((} -7`1�f� c �c <br /> Address: $r (-�C,,G��b�r�'Yy l-f;ll City: C"i�'t;,.�,� 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 8� <br /> Water Supply <br /> ❑ New Construction � Single Family with � Residence <br /> �Addition s;�(�e����r 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 8�permits. ❑ Industrial `"���e SE�ccS � 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�71-0682 <br /> www.m i n nehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ /�, ����— <br /> Last Updated: 4/26/2011 • <br /> - 19 - <br />