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� - � :,. <br /> ��� �;,���^ City of Orono <br /> �� ,�a'� Buildin Permit A li ation � � . �� <br /> 9 pp � 9� <br /> b"*E7 � <br /> � for New Structures or itions <br /> Mailing Address: 4 ��j Permit number. �1 �l(� -C�C'�/-�> <br /> ��A. PO Box 66 C "�� <br /> `v� Crystal Bay, MN 55323-0066 �,'N Date received: � ,� / � <br /> Streef Address.' Pla eived bv� �p <br /> ; ,� 2750 Kelley Parkway �C(� —C��'ZI� -- -- , <br /> - - <br /> ' c.� Orono, MN 55356 r ��{{�� /�` ,�„� n rev ew fee: , �a 7 • `7 <br /> �q . � - �_ — c2,�ac o_ r,�,,,��� <br /> � k F\;s H�� Main: 952-249-4600 -Total Fee: - —7 �` <br /> Fax: 952-249-4616 www.ci.orono.mn.us �� <br /> This application form must be completed in full and all required information ust be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �►� � �gC� ��nC;i�. p� �-��,�.�, rn�i j���� � <br /> Will this be a Parade of Homes, Remodelers Showcase Home or ot er Display Home? ❑ Yes No <br /> If yes,a specia/event permit is required with Police Oepartment and City Council approval 60 days prior to the event. Shuttle bus service wil/be <br /> required un/ess applicant demonstrates su�cient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: . <br /> Name: �);v� �vt`GavV� Ifh �C`r �15�'��.��C>V� .1, �1G. <br /> State License# " �[>�-}3y� Expiration Date: 'Z� ;� �e � <br /> Phone: cell i , Z , p 1 office -- <br /> Mailing Address: ' ')I 1 - tb � C. Cit :'tJU1�.+ .�,� er; <br /> Contact Person: i 2 w.y�n Applicant is: Contractor / omeow (Circle One) <br /> Email andlor Fax: °�'.Qut�i�� ���.�1rvt. � Z <br /> PROPERTY OWNER,INFORMATION: , . _ <br /> Name: r 1\�G�l�� 4 ��`\�l �C,�►.ir'�S`v <br /> Phone(day): �, �� . , '"5 <br /> Address: .�"'-.,f� � Ci : ` �.�� ZIP: �4�7 <br /> Email and/or Fax �G tr�� �L-.�v1 etG, �,ax �v� .. �;y1 <br /> ARCHITECT/ENGINEER INFORMA ON: � , <br /> Name: :.ri > :�:P r ►' �' �" �� � <br /> Phone(day): �Z, Z ' - t <br /> Address: 'z c:61 ' �. Ci :� 1 '�nc%�..'� ZIP:�� `'� <br /> Email and/or Fax: .�tit�, ,,,�r � L-• � • (���:�}� � L� .`� <br /> PROJECT INFORMATION: Descri tion of ro�ect: �.: � ', �` ��1 ' ��G�h�, :�'� /1,,�c�; <br /> 1.Type of Project 2.Proposed Use 3.Structure Ty 4.Sewage Di osal& <br /> ��� Water Supply <br /> �New Construction �l/� �{Single Family with . �,$�G�ea9av�/�{ <br /> ❑Addition � attached garage ❑ Deck �Public Sewer <br /> ' + ❑ ❑Office/Commercial <br /> Relocation �Residence ❑ Private Sewer <br /> ❑Other: (specify) ultiple Fami y Condo Retaining Wall(s) <br /> ❑ Public 4-feet or greater ❑ Public Water <br /> ""Any earth movement may require ❑Commercial ❑Storage <br /> MCWD review&permits. Industrial ❑Warehouse �Private Well <br /> Minnehaha Creek Watershed District(MCWD) ther: (S eCi ) ❑Othe�(SpeCify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �j�) d�� <br /> I ' <br /> Packet Last Updated: August 2015 <br /> Page 21 <br />