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1�� `� �Sg . ta�- City of Orono �,� �, <br /> � ' Buildin Permit A�` lic�� , - ��'OIM.�.3 <br /> J pp - <br /> far New Structures or Additions <br /> �0 A T �g � Mailing Address: � ����� .�..�..�.b.� �' __O�� /'_ <br /> Permi num er: �Q <br /> `VQ Crystal Bay, MN 55323-0 6 Date received: � �l"�L <br /> StreetAddress:' Rec ' <br /> �,� ,� 2750 Kelley Parkway � Pla re i w fe : Q�C'I��'�1�� <br /> �` Orono, MN 55356 G/�.., <br /> !�k@SH04� Main: 952-249-4600 T ee: 9D� < V <br /> Fax: 952-249-4616 �n�ww.ci.orono.mn.us <br /> This application form must be completed in full and all required information must su mitt . <br /> Incomplete applications will be returned. (Please print) ���„�M <br /> GENERAL INFORMATION: �/y�S�' <br /> Job Site Address: jm 3 � j-� y 7 �� L (,,� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> If 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 will not be allowed. <br /> CONTRACTOR/APP, ICANT INFOJ,2M�4TION: <br /> Name: S �►,, ��q �i � C�r Mu.,w e <br /> State License# (� 3 Expiration Date: �� <br /> Phone: cell !� � - � r office <br /> Mailing Address: ,s�a � /_�o ,�c-n C:-c/ Cit : �,., s �/� ZIP: .$'��G(„ <br /> Contact Person: C , Applicant is: Contrac o / Homeowner (Circle One) <br /> Email andbr Fax: S M � „ , �v w� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ����� Frrtz <br /> Phone (day): <br /> Address: /o�� /��� r��y r� C,� City: '1��y Z�-�-r+ ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: �J <br /> Name: <br /> Phone (day): <br /> Address: � Cit : ZIP: <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: 1Z � <br /> Name: � <br /> Phone (day): <br /> Address: Cit : ZIP: <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 /> Water Supply <br /> ❑ New Constructio ❑ Single Family with ❑ Accessory Bldg./Garage <br /> Addition attached garage ❑ Deck ❑ Public Sewer <br /> ❑ Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation �J� detached garage ❑ Residence ❑ Septic <br /> �] Other: (specify) . :ll- ❑ 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 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orc <br /> Estimated Construction Valuation (excluding land) $ �S�o�.. .— <br /> � <br /> Packet Last Updated: January 2016 ��� <br /> Page 21 <br />