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� � City of Orono Building Permit Application ,� for New Structures or Additions -�;7�� 7� Mailing Address: permit number: p'�//-f C°J� ✓'� O�D,�.O PO Box 66 Crystal Bay, MN 55323-0066 Date received: � oz0/� ,� �, StreetAddress:' Received by: 's'�c,t . Gti�' 2750 Kelley Parkway Plan review#ee: 3 • 3% �EsH�4'� Orono, MN 55356 a ��a�� Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be retumed. (Please print) GENERAL INFORMATION: Job Site Address: 3��'S 11��' Sfi�r✓� 1�l"• Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes �No If yes,a specra/event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will e required unless applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. CONTRACTOR/APPLICANT INFORMATION: � Name: �, P� lo t1z�m�� +a- State License# {2y�c�� Expiration Date: ?��I 2�'i Phone: �j52-i�'1 D�le�i��.i� (office) G;12.-F�d0 � �17� (cell) Mailing Address: �,� -; Dt Cit :,� �s Iv� ZIP: SS�_�` Contact Person: �,ri Applicant is: E ac o / Homeowner (CircleOne) Email and/or Fax: ��, :.y c�Q;��, �� cs d ��v+ PROPERTY OWNER INFORMATION: . Name: �Ui k� pft � 5 i/n�= Phone (day): (,<��..— 7�g �- �S �S Address: i 5��'Z vr+�Ai�+G� �i� City: LC7r. �S �--'�E ZIP: ��s�C� Email and/or Fax ��P S i m t: 4= /FvL ��" ARCHITECT/ENGINEER INFORMATION: Name: �I'1�!'it7R�'T �E�sl�;n� Phone(day): �I Si.~ �-4"7 C5 � �''"1_S� Address: q:�c�- Z :�• s'i. ��1- 1 C 0 City:��;,,5 jcs � ZIP: j�� Email and/or Fax: PROJECT INFORMATION: 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8� Water Supply �New Construction �Single Family with ��Residence ❑Addition attached garage Garage/Accessory Bldg. �Public Sewer ❑Accessory Building �Single Family with ❑ Deck ❑ Relocation detached garage ❑Office/Commercial ❑ Private Sewer ❑Other: (specify) ❑Multiple Family/Condo ❑Warehouse ❑ Public ❑ Storage ❑ Public Water **Any earth movement may require ❑Commercial ❑Other(specify) MCWD re�iew&permits. ❑ Industrial �Private Well Minnehaha Creek Watershed District(MCWD) ❑Othe�: (specify) 18202 Minnetonka Blvd Deephaven,MN 55391 Phone: 952-471-0590 Fax: 952-471-0682 www.m innehahacreek.or Estimated Construction Valuation (excluding land) $ yL�, p��s Last Updated: 12/21/2010 - 19-