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68/28/2012 07:04PM 9524407310 (-��""__ VICKITERCERO PAGE 01/05 <br /> , a �, <br /> , �_ �p-13 <br /> C�TY OF ORONO <br /> BUIL�INC� PERMIT APPLICATIOIV <br /> �OR NEW STRUCTURES 4R A�DITIaNS <br /> ,���� Ma�ling Addt'e�ss: Permit number.' OZO/3 �OD 7 <br /> Po r3oX ss <br /> Gnysfa�Bay,MN a��a323-00�8 Date reaeived: <br /> Sb�t Addiess:' Received by <br /> � �' z75o Ke�fey ParKwaY Phan reviewi+�e� <br /> `�l,qk sHOAr��� Orono, MN 55356 <br /> T����: /��. �3 <br /> Main: 952 249�60Q Fax_ 96224&4616 .v_wvu�c,ci.o.tono.mn,_u� <br /> "�s applir,ation:form.�;be comp�ei�irr�u�f;ar.�ci all,;requir�cl:ir.rFarmation mtist,be`subm�ted:' <br /> . . . . ... ._.. . <br /> � � . : on��ei[II Eie:r.e�rne�i:. lP/e�se print) <br /> ,.�..P�� ........ ......_.._..,....... <br /> dENERAL INFORMATlQN: <br /> Job 5ite Acidress: �, � �� 1_,�r�� c� <br /> WVill this be a Parade of Homes, Remodel�rs Showcsse Home or other Display Home� Yes No <br /> �yes,a specfa/cv�nt pennit ts requA�er!with Pblke fl�er6nent and•C�Ty Counc�l epprovsf fi0 days prior to the ewnL ShutNc bus�er,rrce wil!be <br /> requAred u�ss applicBnt demorrstrates suf�ciaret an-s�7e p8Ylcirfg fs s veil9iile. NOIt-pet'mHred e�lN1f,�w)p nOt be a�bwed. <br /> CONTRACTOR/hPPLICANT IN�ORMATION: <br /> Name: r►� �h;�� <br /> Skate Licer�e# ExpiraEion[7ate: '3// <br /> Phone: cell Z,. ��_ �a"z office �i'�2- Z`�-�l <br /> Mailing Address: 8"1 , �-�v.r I 0 1 C� : 2.� ZIP. �3'1� <br /> Cor�tact P�rson� V i uL r T.PJv—c.t�r a Applicant is: tra�� I dm�owr�er tc�aa a�� <br /> Emait and/or Fax: v-�-�v�[��o c��-�,f�'s�d • �.a�, ��s�z-�a•-��3 r o <br /> PROPERTY OWN�INFORMATION: <br /> Name: �or r� a� <br /> AI-bne(day): 5�• y-7 fo• D''s 'i� <br /> Address: � 1 i� •trv��- t_.r�,e. P�da�� City: �ro�►u zIP: �°53��r <br /> Errraif anci/ur Fdx S �p,r� �h,l � r�� .C,dyr1 <br /> ARCHITECTt�TIGIN�dt iNFORMflTION: <br /> Name- <br /> Phone(d�y): <br /> Address: C' : ZIP: <br /> Errrdil and/or F�x: <br /> PRO.l�CT IN�ORMATION: Descri ion af �ect: <br /> 1.'rype of Pro)ec�t 2:ProposEd Use 3.Structura type 4_Sewage Disposal 8. <br /> Water Supp[y <br /> New Constriaction ❑Single Farrrily wikh 0 Ftesidenoe <br /> Additian at�eChed garage ❑Garag�I Aocessory Btdg, ❑ Public Sewer <br /> ❑Aoce�.sory Building ❑ Single.Family wilt► Deck <br /> �Reloption o x)� detached garage �OfficelGommercial ❑Private 5ewer <br /> ❑Clther.(specify) � ( C]MuE�ple Famiry/Condo ❑Warehouse <br /> ❑Public �8twage ❑PubliC Waber <br /> "*Any earth movement may a15o nequire ❑Cflmmercial dl�er(specxty) <br /> MCW�t�eVleY1►�pertnits. ❑Industriaf ❑ privatv Well <br /> Minnehehe Creek Wetershed Disfict(MCWD) ❑ot�,��;ry) <br /> 48202 N6nnetonka Blvd � <br /> DesphaVeq,MN 55391 " <br /> Phone: 952-477-0590 <br /> Fax: 952�71-0682 <br /> www.minnehehacreek or <br /> �stimated Construc#ion Val�tion(exciuding[and) � �� <br />