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City of Qrono <br /> . ` Building Permit Application <br /> far New Structures or Additions <br /> Mailing Address: Permit number: d� — (� <br /> QA, PO Box 66 <br /> � l v� Crystal Bay, MN 55323-0066 Date received: `/ — <br /> Street Address:� � Received by: C� <br /> y� ,� 2750 Kelley Parkway ��� �/�� Plan review fee: � d �� <br /> �` Orono, MN 55356 �, � <br /> �'�k�sHo�``` 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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � �O L�p,-r ,�'(- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f yes, a special event permit is required with Police Department and City Council approva/60 days prior fo the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non�ermitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �Q�C-..G. F•p�t��-41M1°t(r-1,� <br /> State License# Expiration Date: <br /> Phone: (cell) (0l2 - 2�5— �,�CO (office) <br /> Mailing Address: _ � Cit : Ov'e��o S�� <br /> Contact Person: �ft.F� �<.q--2��/Z� Applicant is: Contractor / omeowner �c��ae o�e� <br /> Email and/or Fax: ��r ✓� � Gy�y�,� , � csm <br /> PROPERTY OWNER INFORMATION• <br /> Name: �re�a� ka�vn��/k <br /> Phone (day): U,�2.-Zb�'-�g�� <br /> Address: �u LEP,-� ST CitY: (S�rca ZIP: ���ZF <br /> Email and/or Fax ci Kct-1�rr,c:r1� (�j qrv�c�.� � � tv,,.-� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: Z�p; <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: Z�p; <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8� <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑Accessory Bldg./Garage <br /> ❑Addition attached garage Deck ❑ Public Sewer <br /> ❑Accessory Bui►ding ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence ❑ Septic <br /> '�Other: (specify) � ���� ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Pubtic 4-feet or greater may be required) <br /> '"Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑ Other(SpeCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ D <br /> Packet Last Updated: January 2016 <br /> Paae 91 <br />