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• � <br /> City of Orono . . ��, <br /> � <br /> B il in Permit A lication � <br /> u d g pp � <br /> for New Structures or Additions l <br /> Mailing Address: <br /> �Q� PO Box 66 Permit number: o��� '��� <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> Street Address:� Received by: <br /> � ,� 2750 Kelley Parkway Plan review fee: ��1. g <br /> �Ft �� � Orono, MN 55356 O/ -G!O'�� <br /> q'rESHO�� Main: 952-259-4600 Total F : � � <br /> Fax: 952-249-4616 www.ci.orono.mn.us In,(,(1 <br /> This application form must be completed in full and all required information must be mitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �7 � � �C� ; '1r'�.�= <br /> Will this be a Parade of Homes, Remo elers Showcase Home or other Display Home? ❑ Yes o <br /> If yes, a specia/event permit rs 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-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �1'�'� ��Lr.;�(-E�/-=� �1 �.�1/ ' i_C� <br /> State License# �, ' ' O Expiration Date: �� j(,a <br /> Phone: cell (p ?�,�'• �'; Z office Z � 'Z S <br /> Mailing Address: - ,� Cit : ' � ZIP: �j(P <br /> Contact Person: <• n1 ', � Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: /� ' �� �r�l �� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��"v�nl� �prv�✓�y <br /> Phone (day): —� '�� � <br /> Address: �(r� n�;.�('j�1,�� j� City:/�(i�J'rv►� ZIP: �� <br /> Email and/or Fax ( " �f�� � (����� � Shoyut h.� ��-,ryl <br /> ARCHITECT 1 ENGINEER INFORMATION: <br /> Name: �r��'L�� �'��L(_,�� I'��.nN� <br /> Phone (day): �{c�Z y�� c��-��I <br /> Address: �— Cit : ZIP: <br /> Email and/or Fax: ��/�/�L�'.Y� Lk�rv��=i� Y'r�s1r� [.�/1 <br /> —� <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> �� Water Supply <br /> �ew Construction �Single Family with ,�ttesidence <br /> ddition attached garage ❑ Garage/Accessory Bldg. �ublic Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage �Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ i���(S�7 <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />