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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> //�\\\ ' MailiPO Bo�r66 Permit number: ��L -�S�oJr <br /> O �V Crystal Bay, MN 55323-0066 Date received: ��� /� <br /> �� � �� , <br /> y>^`,� � <br /> a � � n;, w� Street Address:' Received by: <br /> ��'� '' y�,�j�._ �:� I' 2750 Kelley Parkway Plan review fe : <br /> ���SH�4'�/ ' Orono, MN 55356 <br /> ��-� Total Fee: ��� <br /> Main: 952-249-4600 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 INFORMATION: <br /> Job Site Address: j�`�j - � �. o r-��Y�C% f'17I�/ J S��j � <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 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: �Dd�1►� I �u. `��-t C_L� �::►`1S��'uL.-� '�vti1 `J��V�C_e..S �C <br /> State License# �O(�3G 0(c�. Expiration Date: �-3� -)a <br /> Phone: -7 a- �O office cell <br /> MailingAddress: 07700 ��th VY- Cit : ZIP: j " O <br /> Contact Person: {,Y Y o-�Sov1 Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: � c� S�►� � � t 5 �1 c ��v, Cc;rv� <br /> PROPERTY OWNER N ORMATION: ( � ) <br /> Name: - �S\ �.G-1EJ S�� ( -� <br /> Phone (day): — <br /> Address: � <br /> �.�,� �� ��t : � Z�P: � s�3� ( <br /> Email and/or Fax <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 ���C 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> � Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence <br /> ❑Addition ��V� attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse ❑ Private Sewer <br /> ❑ Public ❑ Storage ❑ Public Water <br /> *"Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�permits. ❑ Industrial <br /> Minnehaha Creek Watershed District MCWD ❑ Private Well <br /> ( ) ❑ 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) $ --� <br /> Last Updated: 4/26/2011 <br /> - 19- <br />