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- ' , . � � City of Orono � <br /> Building Permit Application � �P <br /> for tVew Structures or Addition � <br /> � ' <br /> Mailing Address: Permit number: �t/� �� �� � <br /> �O�Q C�rysBtal Bay, MN 55323-0066 � Date received: ��� ' �0 <br /> Street Address:' � �1 Received by: �� <br /> � ,�- 2750 Kelley Parkway � '� Plan review fee: � �� <br /> y� �` Orono, MN 55356 �� <br /> �'�kesxo�`� Main: 952-249-4600 Total Fee: a c ��-U � � � <br /> Fax: 952-249-4616 wv,�vv ci.oren�;mr�.us <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) �C�,� - o3s�? � <br /> GENERAL INFORMATION: ` dv/�.-o� y-{�7 <br /> J�ob Site Address: � �J� �i1� L� l�l w� �t f� <br /> ��"� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f yes, a special event permit is required with Po/ice Department and City Counci/approva/60 days prior to the event. Shutt/e bus service wi/l be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT/INFORMATION: <br /> Name: �1-� (�^t�_`�'��('� � o v.1 �..l�.sil i— <br /> State License# �1 �� �(o( Expiration Date: �p(1 <br /> Phone: cell 1Z- 'i- - 4 office - �-- �?? <br /> Mailing Address: '+ £, Cit �: . :4' ZIP: c�, <br /> Contact Person: � ;-� Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax:� , ,� ,; 1L1;cv� , � <br /> PROPERTY OWNER IpIFORMATION: � I <br /> Name: /l��/�Cp " yuZfJ�K/� V6kNSIZ�� <br /> Phone (day): / - (y0- (v/o� <br /> Address: l�tcC� L� , Cit : 02�Ko ziP: �535 9 <br /> Email and/or Fax Gr Sr !�' �c G <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: r Yc� � ��0 �.10 ll�l <br /> Phone (day): Q 2- g^ Y'4 <br /> Address: $'1�qj pM�c�'1d- A�S Op i Vl Cit : ZIP: <br /> Email and/or Fax: [.,(� C�"(� {�a/�}htti�l�C..��- <br /> ' ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> � Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <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 ❑ 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) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 � ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ [� C��n " <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />