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_ City of Qrono <br /> � � � Building Permit Application <br /> � � , for New Structures or Additions <br /> Mailing Address: <br /> Q�T PO Box 66 Permit number: (%��7'� <br /> � `�� Crystal Bay, MN 55323-0066 Date received: � �ZC� ` l' <br /> Street Address:' -- �(.`:' C,VZ <br /> � ,� 2750 Kelley Parkway ,�I.> <br /> y�' c? Orono, MN 55356 �� / - (.�(� P� {review fee: / � <br /> ��kfSH�4'� 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 all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: � �� /� ���j ��, <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> /f yes, a special event permit is required with Police Department and City Council approva/60 days prior to the event. Shutt/e bus service w�e <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: �21�N �5, I�G�r2� <br /> State License# Expiration Date: <br /> Phone: cell l2 �D� 21 (office) <br /> Mailing Address: N � i2 (z, Cit : �8 � <br /> Contact Person: „� Applicant is: Contra r / Ho• eowner �c����e o�e� <br /> Email and/or Fax: � �, �-q , �� � � <br /> �� <br /> PROPERT'Y OWNER INFORMATION: <br /> Name: �2�� (a cr�y4+2� <br /> Phone (day): 3�— � <br /> Address: /y�� r �}�s� CitY� �/'c'C7� ZIP• ���� <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: Z�p• <br /> Email and/or Fax: <br /> ARCHITECT/ENGINEER INFORMATION: • <br /> Name: - ��-� <br /> Phone (day): �Z- <br /> Address: O/ � T ' Cit : � �ei� ZIP: .`���' � <br /> Email and/or Fax: <br /> ' ��Xf..�c o� <br /> PROJECT INFORMATION: Description of project: I�°iyr � -'7e`r /� �jY' �� l , ,� . <br /> 1.Type of Project 2. Proposed Use `" 3. Struct re Type 4. Sewage isposal& <br /> ❑ New Construction Water Supply <br /> ❑Single Family with ❑Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑Accesso Buildin ❑ Public Sewer <br /> ry g ❑ Single Family with ❑ Office/Commercial <br /> ❑ Relocation i- � ` detached garage � Residence ❑Septic <br /> [�'Other:(specify) [� �A ❑ 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 <br /> ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) � Other: (speCify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 ❑ P�iv2te Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ �� p�fl <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />