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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailrng Address: Permit number: a���-�d 6 3 <br /> ��,Q„Q��\ PO Box 66 -1 - 3_ �Z <br /> �' �`Y Crystal Bay,MN 55323-0066 Date received: <br /> ', _ �4�: .r, � Received b : <br /> `� �'���p,_;i�- �,� Streef Address:' __--::"._._.._..._Y----- <br /> � �i� titi/ 2750 Kelley Parkway Plan reviewfee: o2��a����3 � <br /> �rR���o4,�yG Orono, MN 55356 �QD(v.(�/ <br /> `,-`---,/ -- ,--�.__ <br /> Main: 952-249-11600 Fax: 952-249-4616 www.ci.orono.mn.us � �� Y� �� ��� ">� � y�� <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ,�� <br /> Job Site Address: � � � <br /> Will this be a Parade of Homes, Remodeler Showcase H�me •r�ther Display Home? ❑ Yes No <br /> !f yes,a specra!eveni permrt is required with Police Department and City Counci!approval 60 days prior to the event. Shuttle bus service will e <br /> required unless applrcant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: � �� � � <br /> State License# Z...O �S 4- Expiration Date: 313 i � 3 <br /> Phone: "z 3— ' - 'Z..c� office �Z(a 4'Z.� 1 3� � cell <br /> Mailing Address: 4-�c�o '� ► �1 yCit � v� � .��-- ZIP: r'a 5 3�.� <br /> C o n t a c t P e r s o n: c�o.,"� c�-- Applicant is: ontrac o / Homeowner (Circle One) <br /> Email and/or Fax: ,, c,� v�s� ' `� L 1 <br /> PROPERTY OWNER INFOR�TION: : <br /> Name: �. <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINE�Ej� It��ORMATION: <br /> Name: __!S,� <br /> Phone (day): <br /> Address: City: ZI P: . <br /> Email and/or Fax: . <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> �New Construction �..Single Family with Residence � <br /> ❑Addition attached garage �Garage/Accessory Bldg. �Public 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 /> MC1NC�review&permits. ❑ lndustrial ❑Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑Other: (Specify) <br /> 13202 tYtinnetonka Blvd <br /> Ceephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> wv��w sminneliahacreek.or <br /> Estimated Construction Valuation (excluding land} $ j � C� p V �� <br /> :-'�,,���,�� .�, 3 ;.�:SS � �� � ' �'� <br /> � i �� <br />