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<br /> ���lc���� ��rr��t A���ic�t�a� /
<br /> �'c�r ���r ��r�ct�res �r �.c�����c��s
<br /> Mailing Address: � "�`-
<br /> Q,�r PO Box 66 Permit number: �f�-�j��
<br /> � �VQ Crystal Bay, MN 55323-0066 Date received: _������(,)
<br /> Streef Address:' Received by:
<br /> y ,� 2750 Kelley Parkway �-,� /_ f
<br /> `� �` Orono, MN 55356 L-� '�/ � U lan review fee: � `
<br /> , . ,c�, ,
<br /> �kESH��� Main: 952-249-4600 �-���''� Total Fee:C
<br /> Fax: 952-249-4616 www.ci.orono.mn.us S
<br /> This application form must be completed in full and all required information must be submitted.
<br /> Incomplete applications will be returned. (Pfease print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �1�.a�,�,�,�;,� �..,e,�,�,�; �`� .t_
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �] No
<br /> If yes,a specral event permit is required with Police Department and City Council approval 60 days prior fo the event. Shuttle bus service will be
<br /> requrred unless applicant demonstrates sufficient on-site parking is avaifable. Non-permitted events will not b�allowed.
<br /> CONTRACTOR/APPLI ANT INFORMATIQN:
<br /> Name: hC'_� 1C\!,��-!ae � �...
<br /> State License# r e-; ; 4%��;f:�-i�, Expiration Date: . -��3 r I%
<br /> Phone: cell "��_ �,�-�j -•C7� C.' � office � d�-`��f-� -�,6�'�-.
<br /> Mailing Address: 'y� � ��,��� '� \ � �ycZ �. Cit : ` y�" Z�p. �� V
<br /> Contact Person: � �' �Y rR1��r Qc;� Applicant is: Contractor / Homeowner (CircleOne)
<br /> Email and/or Fax: �G,�n�'�'� _�.�,-,����cx't� C� � '��4� �� ,r! � ^�i�-�
<br /> PROPERTY OWNER INFORMATI N:
<br /> Name: � �=�s' Hc �i'n� L.-l� �-,��,
<br /> Phone (day): �,�a_. �cj` _ ��..���
<br /> Address: -� b� .�rr��ct �d�. 3C� :-� City: (� 1
<br /> Email and/or Fax V�����. , p � ZIP: �j'��U�
<br /> �rc�.�,a����^� ��� ay..�a.���1 L : Cs;��n--,
<br /> ARCHITECT/ ENGINEER INFORII(IATION:
<br /> Name: ��c..h�G�l�a �.t\Y''`�-� �r'�'�►�'�`��
<br /> Phone (day): �_,��. ���� �~�.��
<br /> Address: �,��:�, �.-•J 2 -t" '_ �� . Cit : �i 1 � ZIP: ���'1��
<br /> Email and/or Fax: �.,,���\� ��, ��e,,��3�,� ���,��
<br /> ARCHITECT/ ENGINEER INFORMATION:
<br /> Name:
<br /> Phone (day):
<br /> Address: _ City: Z�p•
<br /> Email and/or Fax:
<br /> i
<br /> PROJECT INFORMATION: Description of project: ���-�: �
<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
<br /> ❑ Accessory Building ❑ Sin le Famil with �ublic Sewer
<br /> ❑ Relocation g y ❑ Office/Commercial
<br /> detached garage -�.Residence
<br /> ❑ Other: (specify) ❑ Multi le Famil /Condo ❑ Septic
<br /> P y ❑ Retaining Wall(s) (Compliance certificate
<br /> ❑ Public 4-feet or greater may be required)
<br /> *i`Any earth movement may require ❑ Commercial ❑ Storage
<br /> MCWD review& 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.orQ
<br /> Estimated Construction Valuation (excluding land) $
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