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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: ,.. <br /> Q PO Box 66 Permit number. b( -6 3(� <br /> � �� Crystal Bay, MN 55323-0066 oate received: �2- �l -�3 <br /> �1 StreetAddress:' Received by: ��� <br /> y\, ,� 2750 Kelley Parkway Plan review fee: <br /> F�� c? Orono, MN 55356 <br /> �'�fSHO�� Main: 952-259-4600 TotalFee: d013'Ol3D <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 INFORMATInN� �/ <br /> Job Site Address: � � N�; � (L b„� �j �' ,,� <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 DepaRment and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT N ORMATION: <br /> Name: ' ,��'��'� ✓� �. <br /> State License# � Expiration Date: -l�f <br /> Phone: cell -�(, � " - office � - <br /> Mailing Address: p '� �� Cit : ' � ZIP: � <br /> Contact Person: f , v�1�� e � T�y�.(l�Applicant is: on ractor,�/ Homeowner �c��ae o�e� <br /> Email and/or Fax: ,��... L✓,� j i t��y� +�4����Cc�+e'-.a•C;r�ti -//����a'� !�1(G�s�`�r'���,lJ��o�*cg. C�.-•-� <br /> PROPERTY OWN R INFORMATION: Q <br /> Name: r�'G� �S ((%� <br /> Phone(day): - � C7- <br /> Address: J �„-•.• ;2 d Cit : Q ZIP: �� <br /> Email and/or Fax (��',' .z ' � <br /> ARCHITECT/ ENGINEER INFORMATION• <br /> Name: `,=c/(� �.� �'�,►�,�� j r���-P� <br /> Phone (day): 5�_��y-�/� <br /> Address: $�/ Gl,� /LD GF�- City: /°��,in ��e ZIP: -33 7 <br /> Email and/or Fax: ,�,4 v�-�� � 5 �.6n�_ <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> New Construction Water Supply <br /> I� �Single Family with �Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. �ublic Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other:(specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> *"Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other:(SpeCify) <br /> 18202 Minnetonka Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ��`��G� •�/� <br /> Packet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />