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.... <br /> • City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit nurnber: <br /> oA, Po BoXss 2ot - � <br /> � f v0 Crystal Bay, MN 55323-0066 Date received: � �—1 c�--1�� <br /> Street Address:' eceived by: �—G-� <br /> '� ,�* 2750 Kelley Parkway T � t ,C�� <br /> ��'� ��` Orono, MN 55356 _._ ��}�`'��'� ��' �a�eview fee: <br /> �kFSHo� Main: 952-249-4600 �" <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: _�3 � L�i r � c. /�r�C Vv�, �,.� ��/ <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other isplay Home?��❑ Yes � No <br /> I f yes, a specia l even t permi t is require d wi t h Po lice Department an d City Council approval 60 days prior to the event. Shuttle bus service will be <br /> requrred un/ess applicant demonstrates sufficient on-site pa�king is available. Non-permitted events will not be a/lowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: r �I 2 <br /> State License# l3 G(2� 3 l S a Expiration Date: � � <br /> Phone: (cell) f�s I-8�5-/ 6 �oL (office) <br /> Mai�ing Address � Z� ,4 .� ,�P� Cit : M ,� d ZIP: 5 ,. <br /> Contact Person: �,,,� „ r Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: ti .. �,d r�. ' � .�v� <br /> PROPERTY OWNER INFORMATION: <br /> Name: �:�v�r �YAd,/ <br /> Phone (day): 7(��, -�3�_ fj�f?`—� <br /> Address: `7 l�0 I � , Cit : M �,,,, Z�p; �`S � <br /> Email and/or Fax ��-r�;n ��,,-h � �.5.}a�� ,�;v„,��� <br /> ARCHITECT/ ENGINEER �NFORMATION: <br /> Name: /��..�,,,c� � ►�.r�`So I�1�,.� S <br /> Phone (day): 4 o Z— �t�(5 �oy� <br /> Address: � �� 2 O wr"i f.).�-~ f"14-g-�. �� r #� E b Q CitY� C�k�c,h�. ZIP• 66l 3 D <br /> Email and/or Fax: t.� �2.- �,����°,� oc�e � <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 /> �(j Single Family with ❑Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial � Public Sewer <br /> ❑ Relocation detached garage � Residence ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s) <br /> ❑ Public 4-feet or greater �J Public Water <br /> *"Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: s eCi ❑ PrivBte Well <br /> 15320 Minnetonka Blvd � P �� ❑ Othef(SpeClfy) <br /> Minnetonka, MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.m innehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ) 0 Q , D o p <br /> Packet Lasf Updated: January 2015 <br /> Page 20 <br />