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a� <br /> . 4 � <br /> Y <br /> City of Orono ��. <br /> Building Permit Application �� � � <br /> for New Structures or Additions <br /> Mailing Address: Permit number: pJI�J/ � ��,b�p <br /> .���0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: -30 ' / <br /> StreetAddress:' Received by: � <br /> 2750 Kelley Parkway <br /> y� �C` Plan review fee: �, g <br /> c,` Orono, MN 55356 � � � <br /> lqkESHOQ`� Main: 952-259-4600 Total Fee: a4/ -�O (p <br /> 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 returned. (Please print) <br /> GENERAL lNFORMATION: <br /> Job Site Address: c' <br /> Will this be a Parade of Homes, Remodef�rs Showcase Home or other Display Home? ❑ Yes No <br /> !f yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will b <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: <br /> State License# �(� �.�2, y3� Expiration Date: <br /> Phone: cell � J' office <br /> Mailing Address: � Cit : " ZIP: �?� <br /> Contact t'erson: � ` c.�• Applicant is: Contractor / Homeowner (Circle One) <br /> Email anc!/or Fax: �D;� �u(1}Sorl R V `��►l�.0�'�ZS , �f""T-' <br /> PROP�RTY OWNER INFORMATION: <br /> Name: �6.l��� S�T/�,L�p'g.�V <br /> Phone (day): -��— �] ���3 <br /> Address: _l 2a5 ��,�U �vt�tT i�� c�tv� a�s�C.��D ziP: 5',3`� l` <br /> cmail and/or Fax. �"�N.t�_$�T/�LV �2 � !Al/ � CQ�`�'( <br /> ARCHITECT/ENGINEER INFORMATION: <br /> tvarne: t!� �j� �� o iZ �-v�KE <br /> Phone (day): Cb /��7�4�-�f(�C�� <br /> Address: � ���_�j�� c�ty: �� ziP: 5�d�� <br /> Email and/or Fax: ��'�) � ,�g�,H��T�V i L.p�--�� , j.���-- <br /> PROJECT INFORMATION: Description of project: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal & <br /> _�/� /' Water Supply <br /> VL(New Construction Single Family with [j�'l�esidence <br /> ❑ Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> I ❑ Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial rivate 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& permits. ❑ Industrial • rivate Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> ( 9 ) � �, �00 E OCQ � �� <br /> Estimated Construction Valuation excludin land <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />