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� <br /> � <br /> � City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> QA> PO Box 66 Permit number: O/ - <br /> � `v0 Crystal Bay, MN 55323-0066 Date received: <br /> StreetAddress:' Received by: j j � ;.._r� �-� <br /> y ,� 2750 Kelley Parkway Plan review fee: � , <br /> '� c,� Orono, MN 55356 <br /> �qKfsHo�� Main: 952-249-4600 p;bl��p--�5�� <br /> Total Fee: <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. �,.r�sy �/9/b <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: �--�f �� , �'� �'��K � <br /> Job Site Address: I„(�� 1-�UN'it2 �z-+�t <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? (�Yes ❑ No <br /> If yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shuttle bus service wil/6e <br /> required unless applicant demonstrates sufficrent on-site parking is availab/e. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> : Name: �1ViNt CuSi��nrl 1-�MES <br /> . State License# C3C-��}29�b Expiration Date: 3-3 i- ZO►.(o <br /> , Phone: (cell) ' (office) �115 --1tv0 2Z`��i <br /> . Mailing Address: '39'] E/.�r�F RLUFF CL�U(2--1' Cit : t-lUp�3 ZIP: �p�io <br /> Contact Person: .� Je f'�' I�f�//� �ISL-y'�{�- f/77 r�;ARplicant is: ontractor / Homeowner �c�►aa ooe� <br /> Email and/or Fax: <br /> - - - �115 - �(�D - ZZq� -�� <br /> PROPERTY OWNER INFORMATION: <br /> Name: SCt.�TT C��Zc�'t-�C]�.�. I AM�( G�zot�1 NoLZ �(Qi rY�Q,� <br /> Phone (day): ej52 _ 33 E{- - ��j�'j <br /> Address: 200� 5�.;�v/.k,ii W Oat� ��L� CitY� d('.�2i� ZIP- '�-�� <br /> Email and/or Fax � ��n- [�fL�l�,�-}t;�L �i.vE�..I.�S F�4fL�t� � M <br /> ARCHITECT NGINEE NFORMATION: <br /> Name: �l E _ �}Ai`ISC�t�i bR�U,� <br /> Phone (day): (o�2-�(� -�� <br /> Address: S�tC�TI ►L►I,�YY1t�.. '�Y`►R N• ��� �- City: ��.��c"�-1 ZIP: �,js`��1 � <br /> Email and/or Fax: n(�UL @ E-�AN�t�1 EifLe� M�l. CCm <br /> PROJECT INFORMATION: Descri tion of pro�ect: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> New Construction �Sin le Famil with Water Supply <br /> g y ❑Accessory Bldg./Garage <br /> dition attached garage ❑ Deck ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage �Residence (�Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) � � <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> �*Any earth movement may require ❑Commercial ❑Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse �Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑Other(speCify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ � � �,� 7� UQl�, L.G� <br /> Packet Last Updated: January 2015 <br /> Page 20 <br />