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, , City of Orono <br /> , . . . . � p, /'� <br /> , Building Permit Application �9 <br /> � for New Structures or Additions <br /> Mailing Address: permit number: f_�/�7�� <br /> Q PO Box 66 �1� <br /> �" �Q Crystal Bay, MN 55323-00 �� Date received: � —ZC� ` I' <br /> Street Address:' � �'�-r' �rZ <br /> � ,� 2750 Kelley Parkway ..- <br /> y�'� c,` Orono, MN 55356 �� .� p(,�(� PI review fee: / � <br /> '�kFs�o��' Main: 952-249-4600 otal Fee: <br /> Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and alt 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, Remodelers Showcase Home or other Display Home? ❑ Yes �� No <br /> If yes,a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service wil/be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted evenfs will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �,211A-N � I�la'rr2 i� <br /> State License# � Expiration Date: <br /> Phone: cell l2 30� �I office <br /> Mailing Address: � f}y2 , Cit : �� � <br /> Contact Person: �� Applicant is: Contra r / Ho eowner (CircleOne) <br /> Email and/or Fax: c� /-�i , ,ra�tJ�� �'f' <br /> PROPERTY OWNER INFORMATION: <br /> Name: �2�� �tr�a4,2� <br /> Phone(day): �a-- / <br /> Address: /�� , ,�/�svr , City: (��QlI/f� ZIP: ���b� <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> ARCHITECT/ENGI EER INFORMATION: � <br /> Name: /rd'Le. <br /> Phone (day): �jiS L-l���, 777 <br /> Address: Cf D/ �'�T ���� City: �GtyZ�i� ZIP: .`�,��'� <br /> Email and/or Fax: <br /> ' � � ,fj� l �%xf'-Gttcn <br /> PROJECT INFORMATION: Description of project: �izr , '7e`r /� r'��i '` ,tr � <br /> 1.Type of Project 2. Proposed Use 3.Struct re Type 4. Sewag isposal 8� <br /> Water Supply <br /> ❑ New Construction ❑Single Family with ❑ Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck ❑ Public Sewer <br /> ❑ Accessory Building ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation i- � ` detached garage � Residence ❑ Septic <br /> �Other:(specify) f� �n ❑ 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&permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCwD) ❑ Other:(specify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq , � <br /> Estimated Construction Valuation (excluding land) $ ?, OiDfl <br /> _,��� <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />