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, ' Cify o� �rono� <br /> �u��dinc� �ermEt �4p�s�icatio� <br /> �or �Eev�r ��r�ctures or �4dditio�ts <br /> Mailing Address: <br /> QA,. PO Box 66 Permit number: �C�/ 7 - ������ <br /> � �VQ Crystal Bay, MN 55323-0066 Date received: �/ �,z j-� � <br /> Sireef Address:' ���l'��� �;=� 'f2�eceived by: U <br /> �� <br /> y ,� 2750 Kelley Pa�lcway Plan review fee: �`--�"o/C�c�� <br /> � L� Orono, MN 55356 ' <br /> �'�kESH��� Main: 952-249-4600 � ` '�"- <br /> Total Fee: ` , � ,�S <br /> Fax: 952-249-4616 v✓wv�.ci.orono.mn.us J- <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) , ,_, �;/��;; � <br /> GENERAL INFORMATION: ` ' ' '�= � <br /> Job Site Address: " �-c"`',�. " ' <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 Deparfinent and City Council approval 60 days prior fo the evenf. Shutt/e bus service ill be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non�ermitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: , ✓�lZ _"jvt c. . <br /> State License# - Expiration Date: � -.� � - j �j <br /> Phone: cell -;� -u 7 -uz-�JC� office <br /> Mailing Address: S �n a �; Cit : ��p. 3 • <br /> Contact Person: Y- �Applicant is: ontractor omeowner (Circle One) <br /> Email and/or Fax: , ` � <br /> 1 <br /> , <br /> PROPERTY OWNER INFORMATION: <br /> Name: �-E? t�1 �l,cf:�,���n <br /> Phone(day): (n 12 � ��1�U�t� <br /> Address: 7��T- g..i��=.a t�s ,�E City ��,•;;, ZIP• <br /> Email and/or Fax �/y��i p,��� � ��„�,�� ,�„Y, <br /> ARCHITECT/ ENGI ER INFORMATION: <br /> Name: Nb i. - <br /> Phone (day): <br /> Address: Cit : � � ZIP: S � ` <br /> Email and/or Fax: , � <br /> ARCHITECT/ ENGINEER INFO ATION: <br /> Name: <br /> Phone(day): <br /> Address: City. Z�P. <br /> Email and/or Fax: <br /> .�x����rx� <br /> PROJECT INFORMATION: Descri tion of pro'ect: 1� �D C + �� - � r� � ;� ,;, <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage sposal& <br /> ❑ New Gonstruction � Sin le Famil with �Nater Supply <br /> ❑Addition g Y ❑ Accessory Bldg./Garage <br /> attached garage �Deck <br /> ❑Accessory Building ❑ Single Family with Office/Commercial � Public Sewer <br /> �Relocation detached garage ❑ Residence ❑ Septic <br /> Other:(specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> "`Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (Specify) ❑ Othe�(speCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehahacreek_aq <br /> Estimated Construction Valuation (excluding land) $ )��s� �; <br /> � <br /> Packet Last Updated: January 2016 <br /> Paqe 21 <br />