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* � V ' <br /> City of Orono $� <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: � Permit number: �U9" �,�`� <br /> ��, PO Box 66 � / � <br /> /O 0,;, Crystal Bay, MN 55323-0066 Date received: <br /> ' e���"� � I; � Received by: G{' <br /> �,,� ``��,��,�, ,,; StreetAddress:' <br /> '�,F,r � � �+^ ��ti�� 2750 Kelley Parkway Plan review fee: ��L�.3. � — �Q' <br /> RxE3H0¢ Orono, MN 55356 pSQ�' <br /> Total Fee: � Q � <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us D� �lj <br /> This application form must be completed in full and ail required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION:� � / /� <br /> Job Site Address: CvF� /V vz�N /`�tcz.� 1�,-z, ��f <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No <br /> /f yes, a special event permit rs required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates su�cient on-site parking rs available. Non-permitted events will not be allowed. <br /> CONTRACTOR I APPLICANT INFORMATIOI�J:, <br /> Name: J-�� �1�.�<v�,�.��.-. 15�iLD[�''/L$ ...�nic. <br /> State License# i �� �' � Expiration Date: ,�,�. Zoid <br /> Phone: �jSZ.. $'�8'-2z2S (office) (cell) <br /> Mailing Address: D/ �'�_ �8"L" ST: Cit : T3�.,�b��v ZIP: Ssy2� <br /> Contact Person: T,�,,�- p,,,NGd a,t c��►�« Applicant is: ontractor Homeowner (CircleOne) <br /> Email and/or Fax: �'�+sT'�"��^' <br /> PROPERTY OWNER INFORMATION: <br /> Name: 1`���.�-- t SH�rz�K�- l�/�--rSa.r` <br /> Phone (day): `�SZ- �-l�z - �-g3g <br /> Address: (r�8'D e,.1ire A,�„1 . „�� City. �2o.vv ZIP: <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 I 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8� <br /> Water Supply <br /> ❑ New Construction ❑ Single Family with ❑ Residence i <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) �'s'3u�� °r ❑ Multiple Family/Condo ❑Warehouse ; <br /> �2cr+ $-'Dc��K ❑ Public ❑ Storage i ❑ Public Water i <br /> "*Any earth movement may require ❑ Commercial �Other(specify) j <br /> MCWD review 8� permits. ❑ Industrial F'o��+ � Private Well I <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify) I <br /> 18202 Minnetonka Blvd � <br /> Deephaven, MN 55391 ' � <br /> Phone: 952-471-0590 � <br /> I Fax: 952-471-0682 I <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ 3 � �"�.� <br /> Last Updated: 6/22/2009 <br /> - 19 - <br /> ,�, <br /> ,,�. <br />