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i � <br /> O` � .� <br /> City of Orono `���1�� '�� <br /> . � � � <br /> Building Permit Application <br /> for New Structures or Additions aio - vo�8/ <br /> Mailing Address: Permit number: �p�0 r�70 b l� <br /> O,¢Q 1��0 PO Box 66 � � �j2YIeK� <br /> �`r Crystal Bay, MN 55323-0066 Date received: <br /> Street Address:' Received by: <br /> � �� Gti� 2750 Kelley Parkway Plan review fee:'� <br /> � , ol�,,y, Orono, MN 55356 <br /> � ��(�7� V <br /> Main: 952-249-4600 Fax: 952-249-4616 www ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> tncomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: , - ' <br /> Job Site Address: -. .' '7; `�Z �� <br /> Will this be a Parade of Homes, Remode{er howcase Home or other Display Home? ❑ Yes ❑ No <br /> If yes, a special event permit is repuired wifh Police Department and City Council approval 60 days prior to fhe event. Shuttle bus service wiH be <br /> requrred unless applicant demonstrates sufficient on�rte parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: t��.�:1=,IC�►�P�c, ��,���t5 <br /> State License# Expiration Date: 3 / 3L/i i <br /> Phone: y 5� �& - z7�.Z 5 (office) (�/Z -��& ��3�c (cell) <br /> Mailing Address: t,�'v/ CA � 7 *� �-2- � Cit : - ,;�r,�r�c-c�.% ZIP: 5` � Z - <br /> Contact Person: ��„4 .�•:;��c.� Applicant is: n ra , / Homeowner (CirdeOne) <br /> Emailand/orFax: RZ+�� C,��tkke:�P�'�.- G'�^�^'t S� �f�$ '�ZS� <br /> PROPERTY OWNER INFORMATION: <br /> Name: TcJ17 Ft�-�� !a�"�� ffiy���1►'J<1�.? <br /> Phone(day): l:i 2- g1� - 2'2�i/ <br /> Address: r� /1'Iy�2T l.t;�...� �c fl 2��� C�Y� [�(Z�n1 c ZIP: 5�39/ <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Dlsposal8� <br /> Waber Supply <br /> ❑New Construction �Single Fami�y 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:(speafy) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑Public ❑Storage ❑Public Water <br /> '"�Any earth movement may require ❑Commercial ❑Other(speafy) <br /> MCWD review 8�permits. ❑Industrial ❑Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑Other:(specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55�1 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation(excluding land) 3 / Z D C7� <br /> Last Updated: 9/29/2009 <br /> - 17- <br />