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. �.r�S �a �� - <br /> , � ,�-�1- Co�,�a-c-�� -� ' �s ' �� �. <br /> �J � �� <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: ����"'OD(J3 <br /> ��O�Q CrysBtal Bay, MN 55323-0066 Date received: J��oS�//!� <br /> � <br /> a �J� ;�, a�� Street Address:' Received by: .�. �. <br /> �'�,c, '' y" �~ 2750 Kelley Parkway Plan review fee: /1� �}" /„?� <br /> L9kESHOg'� Orono, MN 55356 <br /> Total Fee: /�/_/ �G,J <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us f� �J <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 INFORMATION: �� <br /> Job Site Address: �Q �o,��, GqKE � , Q,�n10, /� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes g] No <br /> lf yes,a special 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 demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: A/OQ7Un( t�OM65 <br /> State License# D 5 I�L '�� Expiration Date: ;� 3 i�/� <br /> Phone: 6i�-3�7 - 7 LG/ office 7G -�s/-FJ�oo cell �i.�-�G7(I <br /> Mailing Address: yy/G T��'/t,'v!n !�� City:MEQ��/a ZIP: ���D <br /> Contact Person: (��}�� p(t,-�,�f Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: 7G 3-�S��y'9`f7 <br /> PROPERTY OWNER INFORMATION: <br /> Name: SO�RCE ConISTKUc'T��nl Cf�PITfF�-- <br /> Phone (day): '1(03-,SSj-U I D� <br /> Address: 353s' PL�lMocl'Tt-� Bt�/O �Z/! City: PC..ylU0Jl1{ z�P: SsyyT <br /> Email and/or Fax � ���n/ C�. Soc�P...C.� ^CC. CON` ��3•Ssi- �9 99 <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> New Construction j�Single Family with �Residence <br /> Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private 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 ❑ Private 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 /> Estimated Construction Valuation (excluding land) $ /' 70.ODo.oa <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />