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� � � �l'e- � a�$ , la y- C i ty of �ro n o <br /> . !�fi�0p ��!` '` - <br /> Buiid�ng i�ermit Appl�catiorf a - �{� 011�i <br /> for f�e�rv Structure� or Additions <br /> Mailing Address: � <br /> ,���T �� ' ���`� _ Permi number: p�/ —Q�� <br /> �Vo Crystal Bay, MN 55323-0 6 Date received: � �'���� <br /> Street Address:' Rec ' <br /> y ,� 2750 Keiley Parkway w Pla e i w fe : p�O/�o"�f�� <br /> �' L` Orono, MN 55356 �D' �� <br /> `'kES H�4� Main: 952-249-4600 . ee: <br /> Fax: 952-249-4616 www.ci.orono.mn.us <br /> This appiication form must be completed in full and all required information must� su mitt .,� ,�� <br /> Incomplete applications will be returned. (Please print) ,�.,�v�s�t <br /> GENERAL INFORMATION: <br /> Job Site Address: ��3 S- (.� �f+y��� C,� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> lf yes, a special event permit is required with Police Department and Ciry Council 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 wil!not be allowed. <br /> CONTRACTOR/APP1�ICANT INF0�2ME1TION: <br /> Name: Sh.►.. � f/ o ecf �'1u�4 <br /> State License# (, 3 Expiration Date: � <br /> Phone: cell !� � - '� r � office <br /> Mailing Address: ��a 7 F�o �� C:.-c% Cit : ,, j ../� ZIP: S�1� <br /> Contact Person: t Applicant is: Contrac o / Homeowner (Circle One) <br /> Email and/or Fax: S M '� „ ,�� r-� <br /> PROPERTY OWNER INFORMATION: <br /> Name: _ ���� Frrtt <br /> Phone (day): <br /> Address: /o�-� ^c T�-y e C�,+ City: '11�y Z� 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 /> ARCHITECT I ENGINEER INFORMATION: �'Z � <br /> Name: <br /> Phone(day): <br /> Address: Cit : Z�P: <br /> Email and/or Fax: <br /> PROJECT INFORMATI : Des � ion of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Constructio Water Supply <br /> ❑ Single Family with ❑ Accessory Bldg./Garage <br /> Additfon attached garage ❑ Deck <br /> ❑ Accessory Building ❑ Single Family with ❑ Office/Commercial � Public Sewer <br /> ❑ Relocation � detached garage ❑ Residence <br /> ❑ Septic <br /> �] Other:(specify) - ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> � ❑ Public 4-feet or greater may be required) <br /> **Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review& permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Other(speCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ PrivBte Well <br /> Phone: 952-471-0590 1 Fax: 952-471-0682 <br /> www.m innehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ �i po�� �- <br /> � <br /> Packet Last Updated.� January 2016 ��� � <br /> Page 21 <br />