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� C�� of OronQ <br /> B�ilc�in� �erm�t �4p�fication <br /> for �ev� ��r�ct��-es or �dditions <br /> Mailing Address: <br /> �Q� PO Box 66 Permit number: �p/7-Qj��'�� <br /> Q \� Crystal Bay, MN 55323-0066 � Date received: �-��-�7 <br /> ,V� StreetAddress:' �/�� Received by: '��/j -� � <br /> y ,� � p� � 2750 Kelley Pa � Y 2�, <br /> `°1' ��+� `r�� Orono, MN 55356 � P�an review fee: � du � <br /> k F S H o�` Main: 9 5 2-2 4 9-4 6 0 0 Total Fee: �U��-� <br /> Fax: 952-249-4616 wwn�.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: ;' 7U ;IV�.�,�, _,�„� ),� ;,v� C%/_�awv (/��, a g'3�, ��- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes, a specia/event permit is required with Police Departmeni and City Council approval 60 days prar to the event. Shuttle bus service wil/be <br /> required unless applicanf demonstrates sufficient on-site parking is available. Non-permitted events wil/not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: p(����.� (,w� r c�� � ,N'� �s . • G : ��i1��i11� l�U t;kS C;�f �'1�� " j <br /> State License # (j(.�j pop2�3 ci , Expiratian Date: � l 18• <br /> Phone: (cell) ��z �_ `�,�� - b �i (office) °t�Z `'�3 j -- d�l-�1 3 <br /> Mailing Address: (P� � � � c � _ Cit : �,�, ,ti`, Z�p. �s � z �- <br /> Contact Person: �L}��. ��.,a,.�y Applicant is: ontractor Homeowner (Circle One) <br /> Email and/or Fax: i�c , s.ie a����� L yS p N L DV� ; �'vw► �, `;i i"�I►��l i._:_� �DI hC f�I��1 C" iC��� <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��5�'.¢ �✓��sc� . <br /> Phone(day): �{Sz Z�C� �5��0 <br /> Address: �? 7b ✓v � �,n,R,P .n�, �(J f2 City �vw � ZIP• S �� `�- <br /> Email and/or Fax . <br /> ARCHITECT! ENGINEER INFORMATION: <br /> Name: 1��-✓�� �v c� ��'S � i,` , <br /> Phone (day): �c�z - 9��f-- G'� 7 3 <br /> Address: City: Z�p• <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: _ Citv: ZIP• <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Descri tion of ro'ect: <br /> 1.Type of Project 2. Proposed Use 3.Structure T e <br /> YP 4.Sewage Disposal8 <br /> ❑ New Construction �Single Family with �Accessory Bldg./Garage Water Supply <br /> ❑Addition attached garage Deck <br /> ❑Accessory Building ❑ Single Family with ❑ OfficelCommercial � Public Sewer <br /> ❑ Relocation detached garage ❑ Residence <br /> �Other.(specify) ��-C-- ❑ Multi le Famil /Condo ❑ Septic <br /> p y ❑ Retaining Wall(s) (Compliance certificate <br /> iQ� � . ❑ Public 4-feet or greater may be required) <br /> *`Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review 8�permits. ❑ Industrial ❑Warehouse ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other:(specify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 <br /> Phone: 952-471-0590 / Fax: 952-471-0682 ❑ P�vate Well <br /> www.minnehahacreekoru <br /> Estimated Construction Valuation (excluding land) $ Gf��� _ <br /> Packet Last Updated: January 2016 <br /> PanP �! <br />