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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: ermit number: O J'7 — � � <br /> .�O A,O PO Box 66 _ <br /> `w Crystal Bay, MN 55323-0066 Date received: —/� <br /> StreetAddress:' Received by: �f'C — <br /> a ,�*� 2750 Kelley Parkway � � G,' � <br /> y� Plan review fee: . <br /> t L` Orono, MN 55356 � w �/� <br /> '�kESHo��' Main: 952-249-4600 Total Fee:��"'��._�� �� -" ��T � <br /> Fax: 952-249-4616 www.ci.orono.mn.us p � <br /> This application form must be completed in full and all required information must be submitted. ��� ����` <br /> Incomplete applications will be returned. (P/ease print) 1 i <br /> GENERAL INFORMATION: / <br /> Job Site Address: �4�� ��� !�A'N� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> ff yes,a specia/event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service will be <br /> required unless applicant demonstrates su�cient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORN�ATION: <br /> Name: N- !S(�1f� <br /> State License# �� O�1' 7�{ Expiration Date: -3l - 20jQ <br /> Phone: cell �' - $�- Q� office (-,l Z- 2 �- <br /> Mailing Address: �' '7 �- � S , Cit : �J� IP: ,;,5 D <br /> Contact Person: J� Applicant is: Contractor / omeowner (Clrcle One) <br /> Email and/or Fax: $. <br /> PROPERTY OWNER INFORMATION: <br /> Name: 'jU1,�Q (�t"i 1 SC.�� <br /> Phone(day): 3-5�59-56$�1 <br /> Address: 3` / J�J� Ci : Q (� ZIP: �5�� / <br /> Emailand/orFax �pG_I�,�(SC,�f-� � '(,G v{,�I.� • ('„()J� <br /> ARCHITECT/ENGINEER INFOR ATIQ N: � p �Q,�j�, , �,,� ` <br /> Name: _��.��1+t�'JV��'F�' i""' ri�[jC �u l�G/� .. <br /> Phone (day): 2 - 3 S- � 3� <br /> Address: �f T� , Cit : '��N , nl�tj ZIP: S���[1 <br /> Email and/or Fax: �! i A-�l (' <br /> PROJECT INFORMATION: Description of pro�ect: <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 Building � Single Family with ❑Office/Commercial <br /> ❑ Relocation detached garage Q Residence ❑ Private Sewer <br /> ❑Other:(specify) ❑ Multiple Family!Condo ❑ Retaining Wall(s) <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> ""Any earth movement may require ❑Commercial ❑Storage <br /> MCWD review 8�permits. ❑ Industrial ❑Warehouse �.Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑Other(speCify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952�71-0590 <br /> Fax: 952-471-0682 <br /> www.m i n n e h a h a c ree k.o r <br /> a v.� EIVED <br /> Estimated Construction Valuation (excluding land) $ �OD�r 0� <br /> APR 2 8 ZU1� <br /> Packet Last Updated: August 2015 <br /> Page 21 CITY OF ORONO <br />