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.,. <br /> �'^ <br /> City of Orono <br /> Building Permit Application ,� � <br /> for New Structures or Additions �, 7�� 7-� <br /> Mailing Address: <br /> ��,�,�� PO Box 66 Permit number: p'�/�-��J�✓r <br /> /i�0 , Q�� Crystal Bay, MN 55323-0066 Date received: � oZ0/� <br /> �� �'���� - �! Received b <br /> a i� r���:,;;:�. a, StreetAddress:' Y� <br /> �'�, ?' a" G� 2750 Kelley Parkway Plan review fee: � 9. 3� <br /> �agESHo¢� Orono, MN 55356 a ���d�� <br /> -- � Total Fee: <br /> Main: 952-249-4600 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. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 3C�� 5 IV���.`-T►� s�,'_� .n;'. <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 Department and City Council approval 60 days pnor to the event. Shuttle bus service w�ll e <br /> required un/ess app/icant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: 3�.iz; � r1 �:; ttc's��s �:� <br /> State License# �,p;y� Expiration Date: 3 �� Le� <br /> Phone: �iSL -/-�1�"1C- �:�''�4 (office) G. �Z-4� c+c^ �i 7�3 (cell) <br /> Mailing Address �f�9 Z�Y' ��T �I C� City:.�K�i..��c.�_ ZIP: �� ; ;� <br /> Contact Person: ��,•,� ,,,z �'��•� Applicant is: • rac o / Homeowner (Circle One) <br /> Email and/or Fax: �r���,�r' .zc�,L �fi�*:ri�S i` FAS:: ,, �-c: tv+ <br /> PROPERTY OWNER INFORMATION: _ <br /> Name: 4ti��1�� l�tt ►�� �i/n�_ <br /> Phone (day): (.:.�Z.._ -7C c7 - �t-�� �`S <br /> Address: ►S�i Z �r��i uc� 'h-'-.� City: �...c=-:� ,�� (-�:�<< ZIP: S�>> C�- <br /> Email and/or Fax �M���� .5, n� � 4�- �i-y � � %�^ <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: �fTi1;�f1Gti;"i D�s��•�` <br /> Phone (daY) '^IS� �}"7C;� ��"� �G <br /> Address: �(:q 2 -+. `y i. r-� 1 C"c`� City:��=t •��o �:i ZIP: �`�� -� � <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> �New Construction �Single Family with �Residence <br /> ❑Addition attached garage Garage/Accessory Bldg. ''�Public 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) $ '�%C�}CCC.� <br /> Last Updated: 12/21/2010 <br /> - 19- <br />