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City of OronQ � t�
<br /> Building Permit i4ppl�cation 6��
<br /> for New Structures or �ldditions
<br /> Mailing Address:
<br /> QA,. PO Box 66 Pe��t number: o�'�I�UOSS�O
<br /> � �vQ Crystal Bay, MN 55323-0066 Date received: c/r��j/�
<br /> G,�,y,�\�1 Street Address:' Received by: �/'
<br /> y ,� l��" 2750 Kelley Parkway �/�� (�,s7 �
<br /> �' G� Orono, MN 55356 � Plan review fee: Lj/
<br /> ��kFSHo��' Main: 952-249-4600 TotalFee: ���—�5�+�
<br /> Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This applic�ttEon form must be�ompleted in fulf and all required ir�#ormation must be submitted.
<br /> Incompfete applicattons will be retumecl. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: -�-j L �,,� ��}� �,
<br /> Will this be a Parade of Homes, Remodelers Showcase Ho e or other Display Home? Yes No
<br /> If yes,a special event permit is required wkh Police Department and City Counci!approval 60 days prior to fhe event. Shuttle bus seivice will be
<br /> required unless applicant demonsKrates sufficient on-site parking is available. Non-permitted events will not be aflowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �►n,�-.1h C�,�.��.r�,,�,v,
<br /> State License# � �_ r� L'Z¢?�'3 Exp�ration Date: . ry,-:��.
<br /> Phone: (cell) �/-z- ��q- -�%� Y (office) � 7
<br /> Mailing Address: ,,,��- /z,,,E� ��-c._ Cit : /�,,� Z�P: S. �5,
<br /> Contact Person: -e Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: � ���, �,���� � ���
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ��„� � ,,,�,,.
<br /> Phone(daY)� !01 Z `3 /7'— ���?c�
<br /> Address: /-Z-Z,�y t-,,,,,,,,..,�., y�v ��.,� -, � City p'�v,� ZIP. s-- 3`)�
<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 /> ARCHITECT/ ENGINEER INFORMATION:
<br /> Name:
<br /> Phone(day):
<br /> Address: City. Z�P,
<br /> Email and/or Fax:
<br /> PROJECT INFORMATION: Descri tion of pro'ect:
<br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Dlsposal 8
<br /> ❑ New Construction ❑ Single Family with ❑Accessory Bldg./Garage Water Supply
<br /> ❑Addition attached garage ❑ Deck
<br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial � Public Sewer
<br /> ❑ Relocation detached garage ❑ Residence
<br /> ❑ Septic
<br /> �J Other:(specify) � ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Complfance certificate
<br /> �-c� v�� �� S u w�_ ❑ Public 4-feet or greater may be required)
<br /> *"An arth movement may require�� ❑ �mmercial ❑ Storage
<br /> MCWD review 8 permits. ❑ Industrial ❑Warehouse ❑ Public Water
<br /> Minnehaha Creek Watershed DisVict(MCWD) � pther: (specity) ❑ Other(Specify)
<br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well
<br /> Phone: 952-471-0590 / Fax: 952-471-0682
<br /> www.minnehahacreek.aq
<br /> Estimated Construction Valuation (excluding land) �;Q�$ �.,�
<br /> Packet Last Updated: January 2016 �
<br /> Pa.qe 21 �'7 G'G� _-�' �'—
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