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�i�� �� C�rar�� <br /> . ' ����c�i�c� ���-r�it �4p����c�t�a� <br /> far {���r ��ructures ar �c�dit���s <br /> Mailing Address: <br /> �Q� PO Box 66 Permit number: ��,� --��� <br /> � Crystal Bay, MN 55323-0066 Date received: ���,j <br /> Streef Address:' Received b : <br /> y ,�• 2750 Kelley Parkway i( .. v � <br /> `� �� Orono, MN 55356 �Y� lan review fee: <br /> tqkESH�4� °� ' <br /> Main: 952-249-4600 —��----- !- -_------�_ <br /> Fax: 952-249-4616 www.ci.o ono.mn.us Total Fee; <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: �1�:a�-l��n,r�. '�.,,i �v�� �:�,��� <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 Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitfed evenfs will nof be allowed. <br /> CONTRACTOR/APPLI ANT INFORMATIQN: <br /> Name: h� 1 G����'-�--'��r � � � <br /> State License# `� ; �^�;f��y�, Expiration Date: . "��3� ��. <br /> Phone: cell '��_ ���,.p p � office � ��-`3=f-� -'���,. <br /> Mailing Address: _3� �c,���� ; ;� � vcL �. Cit : � ZIP: �� • <br /> Contact Person: � ' � �k�,�*l�, Applicant is: Contractor / Homeowner <br /> Email andbr Fax: �, , , �,� � (Circle One) <br /> PROPERTY OWNER INFORMATI N: <br /> Name: � �� �� �ti'nr � �._,��ti <br /> Phone (day): � �q 1 _ �^��� <br /> Address: b, �,�,�-r �!e�, �,,,,� Cit : (Y1 � ZIP: �j .,�`� �7� <br /> Email and/or Fax � � ��,��L; �� <br /> ARCHITECT/ ENGIN�R�I�NFOR ATION: <br /> Name: � ,�. � .� <br /> Phone (day): +� -�` 4 -� <br /> Address: � "'��, '�,,,�, ¢ ���, <br /> c�t : (�'� 1 ziP: ���ii0 <br /> Email and/or Fax: �,\ � ; � ��� �� <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: Cit : Z�p: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: 'v�U.� <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> ew Construction Water Supply <br /> �-Single Family with ❑ Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial ��ublic Sewer <br /> ❑ Relocation detached ara e <br /> 9 9 �-Residence <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retainin Wall s � Septic <br /> 9 ( ) (Compliance certificat <br /> ❑ Public 4-feet or greater may be required) <br /> *"Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review 8�permits. ❑ Industrial ❑Warehouse <br /> Minnehaha Creek Watershed District(MCWD) ❑ PubliC Water <br /> ❑ Other: (specify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 <br /> Phone: 952-471-0590 / Fax: 952-471-0682 rivate Well <br /> www.m innehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ <br />