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<br /> City of Orono �� .�
<br /> � �
<br /> Building Permit Appiication� �
<br /> for New Structures or Additions
<br /> Mailing Address: Permit number: �Dl/—��
<br /> �/�,�,�. PO Box 66
<br /> u, � Crystal Bay, MN 55323-0066 Date received: 7 a //
<br /> �� � � Received b 7��
<br /> 'II,a ,y""'K� '`" a,�, Sfreet Address:' y�
<br /> �'�' �� ��'� 2750 Kelle Parkwa � O�': D
<br /> c� ^1�j��x_ Y Y Plan review f�: � �
<br /> \��` ���� g.`�� Orono, MN 55356 b ` �G
<br /> ,,;.�sHo � d " �a
<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 fufl and all required informafion must be submit ed. , �����
<br /> Incomplete applications will be returned. (Please print) 1 ���
<br /> GENERAL INFORMATION:
<br /> Job Site Address: � �e - ,� ,,, , ,
<br /> Will this be a Parade of Homes, Remodelers howcase Home or other Display Home? ❑ Yes No
<br /> lf yes, a specia/event permit is required with Police Department and City Councif 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: /�rc,.s;<�n L���,�'S � C�oh J� �� k )
<br /> State License# .�D.�� 3 n a r,— Expiration Date: 3- I�
<br /> Phone: �L�3 �_5 5 - 5� � � �s�- C�l/ )(c� .��� L��y,;2 y (cell)
<br /> Mailing Address: �j �o <�✓c- C,'��c l� City: /h,�,�i�-/r,:sf�; ZIP: S Sj�y
<br /> Contact Person: ��h �� :n v,'�C Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: �,,��� �S�%�jK; � r o���'1
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ��h�.-� ����rl / ���, I'cts SrL�;'t ��
<br /> Phone (day): �- ,�,� � o � ,
<br /> Address: y�c��- �/;��ti w,,,�,, �� City: ,��'c'�n � ZIP: 55 S'� 7'
<br /> Email and/or Fax "
<br /> ARCHITECT/ ENGINEER INFORMATION:
<br /> Name: /��,ti,e f�l�,.,��,�h� f�� 59G ���1��= S
<br /> Phone (day): ��� - �N(�, ���� �
<br /> Address: __,�3�� �F��t rct f l�vFa�•c= �L�C City: Sp���1t; L�t kc� �`''�LIP: 5 5 '�5:�
<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 attached garage q Garage/Accessory Bldg. ❑ Public Sewer
<br /> ❑Accessory Building �Single Family with Deck
<br /> ❑ Relocation detached garage �'Office/Commercial ❑ Private Sewer
<br /> ❑ Other: (specify) ❑ Muitiple Family/Condo ❑Warehouse
<br /> ❑ Public ❑ Storage ❑ Public Water
<br /> "'Any earth movement may require ❑ Commercial ❑ Other(specify)
<br /> MCWD review&permits. ❑ Industrial �?,r,: �� ❑ Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify)
<br /> 18202 Minnetonka Blvd
<br /> Deephaven, MN 55391
<br /> Phane: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.or
<br /> Estimated Construction Valuation (excluding land) $ l..] � ��-J �
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