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C�ty of Or�r�c� � C� (p� fo.� <br /> �u�lc�in l�ermit ' ` `�i � <br /> � Ap�i�cati�� <br /> f�r �ev� Struct�res or Addit�ons <br /> Mailing Address: ,_7 <br /> Permit number. ��'� <br /> �Q� PO Box 66 , b -'L( .�� <br /> Q Crystal Bay, MN 55323-0066 Date received: /�- �"J - � ,, <br /> Street Address:' � Received by: �%c..�� <br /> y , `,� 2750 Kelley Parkway� � « j� ���r � plan review fee: �� � ,� � . SSZ'> <br /> �' � �Orono, MN 55356 l � ' � <br /> z � �r �� 1.>�-�s- --- __—__--_�J_ <br /> �akFSHo�`�` - Main: 952-249-4600 - <br /> Total Fee: <br /> Fax: 952-249-4616 wv,�w.ci.orono.mn.u� <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORNfATION: ,-� � � <br /> Job Site Address: -? _ - .��� : �\. �;�� ;�� ":C�ti , <br /> Will this be a Parade of Homes, Remodeler�. howcase Hom or other Display Home? ❑ Yes ❑ No <br /> If yes, a specia/event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrafes sufficient on-site parking is availab/e. Non-permitted events wil!not be allowed. <br /> CONTRACTOR/AP��CANT INFORIViAT10N: <br /> Name: . ;n�`_� � ��,� �� � �l�� c_ <br /> State License # <'"' Expiration Date: ,3 1 i ( � <br /> Phone: cell � - � � office '� 1 �' -;�-� <br /> Mailing Address: `] O C c�.c, c�..� �� �;L- Cit : - Z�p; ,��_,� <br /> Contact Person: - Applicant is: on racfaT�:. / ' Homeowner (Circle One) <br /> Email and/or Fax: � � �v,�y, <br /> PROPERTY OWNER I�VFORMATIOfV: �j � ,/ <br /> Name: �FL� `t ,. - °\ -D Q.S�I <br /> � O�r� <br /> Phone (day): �`,� - �c� � � S ' <br /> Address: ��i ,� . c; �,� � Cit : ���Sc ' ZIP: ��.���� Z�'_. <br /> Email and/or Fax _ G �v,� , c� �'� c�r����� • c c�,�t <br /> ARCHITECT/ ENGIN�ER INFORMATION• , <br /> Name: , ,. ;. .����_€_ � - <br /> Phone (day): � � - ,� � �� • � � <br /> Address: ,�� '� Cit : � , .. �_,�- ZIP: �C'� �� 1 <br /> Email and/or Fax: t--1 c�u �-� vJ ,.�-, �n �C z, � LL�}tit � <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: Citv: ZIP• <br /> Email and/or Fax: <br /> PROJECT INFORIVIATION: Description of pro'ect: �� �� ��•� ��f '� � �����"��`' <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> �New Construction Sin le Famil with �Nater Supply <br /> Addition � 9 y ❑ Accessory Bldg./Garage <br />�, attached garage ❑ Deck <br /> ❑Accessory Building ❑ Sin le Famil with ❑ Public Sewer <br /> ❑ Relocation 9 y ❑ Office/Commercial <br /> detached garage ❑ Residence ❑ 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 8�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.m inneha hacreek.ora <br /> Estimated Construction Valuation (excluding land) $ I �� <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />