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� � ��ty o� Oron� 8 <br /> � ��i�c�in� Perrn�t �4p�licatio� ���,� <br /> f�r �e�nr Struct�res or i4ddit�ons <br /> Mailing Address: <br /> Q,�T PO Box 66 Permit number: b[ p� <br /> � :V� Crystal Bay, MN 55323-0066 Date received: /� '"l�—(� <br /> , StreetAddress:' Received by: �/'�}'� / /l./' <br /> � ,� 2750 Kelley Parkway i� � <br /> y�'ak o�ti�� � � Orono, MN 55356 _ ��an review fee: �� � <br /> FSH 1��, Main: 952-249-4600 Total Fee: <br /> Fax: 952-249-4616 wv,nv.ci.orono.mn.u� ' � t��� � 0�L <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 /> GEFlERAL INFORIVOATION: <br /> Job Site Address: � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> lf yes, a specia/event permit is required with Po/ice Department and City Council approva/60 days prior to the event. Shuttle bus service will be <br /> required unless applicanf demonstrates su{ficient on-site parking is available. Non-permitted events will not be alfowed. <br /> COIVTRACTOR/APP�CANT INFORIIAATION: ��r\ <br /> Name: v <br /> State License # _ Id G S"qg��/S - - Expiration D te: <br /> Phone: cell � office <br /> Mailing Address: / " a• Cit : Z�p: � <br /> Contact Person: �l� SU1�1��' Applicant is: C / Homeowner (Circle One) <br /> Email and/or Fax: �� � ��gW�) ��,�, <br /> PROPERTY OWNER INFORMATION: <br /> Name: TJ4�+�T14,A 'RjF-q,/� <br /> Phone(day): �(�c�?Lc�a� <br /> Address: /�� �f���, CitY: /�j�� ZIP� ,��� <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Adciress: City: Z�p� <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMA�TION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP• <br /> Email and/or Fax: <br /> PROJECT INFOF�WIATION: Descri tion of pro'ect: <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal& <br /> Construction Water Supply <br /> ❑Single Family with ❑ Accessory Bldg./Garage <br /> Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Sin le Famil with ❑ Public Sewer <br /> ❑ Relocation 9 Y ❑ Oifice/Commercial <br /> detached garage ❑ Residence ❑ Septic <br /> �Other:(specify) �(JIGI�j ❑ 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+ 8�permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) � Othe�: (SpeCify) ❑ Other(SpeCify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m i nnehahaceeek.ora <br /> Estimated Construction Valuation (excluding land) $ <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />