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C�ty of Orono Z� <br /> � ' �c��lc�i� Permit �4 ficati�r� � � �� <br /> � p� l <br /> far �Eew� �truct�res or Addit��ns <br /> Mailing Address: a�l�^D��D� <br /> A? � PO Box 66 Permit number: <br /> �O�vQ -� r,� ,� Crystal Bay, MN 55323-006uRECEIVE Date received: /p�-D%-/ � <br /> ��J � <br /> �� Street Address:' DEC O � ZO �eceived by: <br /> 2750 Kelle Parkwa (� <br /> � �' Y Y 4��I l� <br /> y�'�� 4�G� Orono, MN 55356 C�TM�F� Olan review fee: <br /> kfsxo Main: 952-249-4600 Total Fee: aG� -p/S <br /> Fax: 952-249-4616 wwvv.ci.oronc.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be retumed. (P/ease print) <br /> GENERAL INFOFZN�ATIOIV: <br /> Job Site Address: `�' �Q (,�:�� � � .��� F���-����� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home? ❑ Yes No <br /> lf yes, a specia/event permit is required with Police Department and City Council approval 60 days prior fo the event. Shuttle bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPL CANT INFORI�►I ATION: <br /> Name: �t� �u lf�' rti•-� 5 <br /> State License # � ,5 Expiration Date: <br /> Phone: (cell) (G f� --7 41' `��6`'� (office) <br /> Mailing Address: Cit : Z�p: <br /> Contact Person: t f�� Applicant is: n actoy/ Homeowner (Circle One) <br /> Email and/or Fax: �k; sef k ����v�Y�a Zc�,tic�; i o w� � <br /> ` <br /> PROPERTY OWNER INFORMATlON: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP• <br /> Email andbr Fax <br /> ARCHITECT/ENGINEER INFIORMATION: � � �� � l <br /> Name: �-�%�� ���� � <br /> Phone (day): / <br /> Address: �� � 9. <br /> �� ZIP: <br /> Email and/or Fax: <br /> � ��. �� <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): ��G �; �// <br /> Address: � � !�� ,�G"�� ZIP: <br /> Email and/or Fax: � ��� � <br /> PROJECT INFORMATION: Description of� ��(��'� �- <br /> 1.Type of Project 2. Prc 4.Sewage Disposal 8� <br /> ew Construction �, <br /> Water Suppfy <br /> ❑Addition y v � e <br /> attached garage U „��,. <br /> ❑Accessory Building ❑ Sin le Famil with ❑ Public Sewer <br /> ❑ Relocation 9 Y ❑ Office/Commercial <br /> detached garage ❑ Residence Septic <br /> ❑ Other:{specify) ❑ Multiple Family/Condo ❑ Retainin Wall s <br /> 9 ( ) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> *''Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review 8�permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Other(SpeCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 rivate Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehahacreek.or4 <br /> Estimated Construction Valuation (excluding land) $ � , � <br /> Packet Last Updated: January 2016 � <br /> Page 21 <br />