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, - <br /> ' City of Orono <br /> -� 95U. �� <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: c�U�(G—D/5(o/ <br /> (�A, PO Box 66 <br /> � `vO Crystal Bay, MN 55323-0066 Date received: l2 Z-Z /f� <br /> StreetAddress:' ��� Received 2� <br /> ~� ,� 2750 Kelley Park y _ �/ � <br /> y�' c.` Orono, MN 55356 ����-��'S6 Z Plan review fee: <br /> (q�t'SHOQ'� Main: 952-249-4600 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. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION��D ���� � <br /> Job Site Address: �i�-� t/-� , �I�(� �,{/ ss�S � <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 approva160 days prior to the event. Shuttle bus service will <br /> required unless applicant demonstrates sufficient on-site parking is avarlable. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT FORMATIO : �' <br /> Name: '�Z �(�-�-rS �- �D !t� .�2 ��Z <br /> State License# S� / Exp,iration Date: - /- <br /> Phone: cell j -- �� office 7Js2 - 7 -- � <br /> Mailing Address: C re v�'.P w c/e Cit : rD nU ZIP: S (�, <br /> Contact Person: /Orr� Z Applicant is: Contractor / omeowner �c���ie o�e� <br /> Email and/or Fax; e Z L,� " ,elS' c� cL L�O . C�j <br /> PROPERTY OWNER INFO MATI,Q N: � l -}- (' ,, <br /> Name: C O`T�` � - r(�� l �C� (� <br /> Phone (day): `�15� - '�{ - i 933 <br /> Address: _� 9(� ' T P �-f y 'P t,�1 ✓e Cit : ��c ZIP: SS�� lr� <br /> mail nd/or Fax �rnc��t '. p �e -e �� C � f� ��1��• GUe-.-, <br /> ARCHITECT/ENGINEER INFORMATION: / <br /> Name: � c /� ,,(�PS� r> �� /n �C � � ?�(�h <br /> Phone (day): � - d - /S <br /> Address: �� v�, Cit : m�n h���i,l�K�ZIP: s���� <br /> Email and/or Fax: " � � � �c . <br /> PROJECT INFORMATION: Descri tion of ro�ect: -�l �lSYl �% ���_ <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ ew Construction ❑ Single Family with ❑Accessory Bldg. /Garage <br /> �Addition 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 [�'rivate 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) $ �� ��-l� <br /> . a <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />