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• . . <br /> City of Orono � �,�'v <br /> � � <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: �O��r <br /> '¢�� PO Box 66 Permit number: Q�'j�' � <br /> � Q Crystal Bay, MN 55323-0066 Date received: , Z �1 <br /> � •�'y F Street Address:' Received by: (�'7'- <br /> �,� , �� 2750 Kelley Parkway Plan review fe : <br /> q'kESH04�' Orono, MN 55356 �! <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. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 5�,,��; �(�j �•�i��� �rf �� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No <br /> If yes, a specra/event permit is required with Police Department and City Council approva!60 days prior to the event. Shuttle bus service wil!be <br /> required unless applicant demonstrates su�cient on-site parking is available, Non-permitted events wi!!not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: IYS F. �1L� �ctil c�c'�I � <br /> State License# _ -; ; / Expiration Date: J/31/�C� <br /> Phone: _ �t S'Z- `t 4 ? - �f- �0 2_ f office) Co('Z _ 5�( 7 _ � (v(c ' - (ce��) <br /> Mailing Address: � L �� � Cit Z�P. <br /> Contact Person: _ .��r �:,. App(icant is: ontractor Homeowner <br /> Email and/or Fax: �c�r�ie o�e� <br /> PROPERTY OWNER INFORMATION: <br /> Name: R�L�q�. r_� I-I/�I �� <br /> Phone (day): 7�� � � <br /> Address: ;� 11<t�- htir� L��'' City �/cirrb ZIP� �� � � _Z <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER II�FORMATION: <br /> Name: V f�v vy�r1 e�S f�� <br /> Phone (day): �S L - � 7 3 3i <br /> Address: I � �-{�Z'Z, GU h i e,� !�i� C�7� Cit : �f��� P�c�in� ZIP: `�j(�CS/� <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1. Type of Project 2. Proposed Use 3.Structure T <br /> ype 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction [�Single Family with Residence <br /> ❑Addition attached ara e <br /> ❑ Accesso Buildin , g 9 ❑ Garage/Accessory Bldg. [-J'f�ubfic Sewer <br /> �' 9 �'��s� ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached ara e <br /> 9 9 ❑ Office/Commercial ❑ Private Sewer <br /> �ther: (specify) �c:ic.(�ch irn t/ ❑ Muttiple Family/Condo ❑Warehouse <br /> �'�����`' °����' ����'=-�"�'tL�-'C ❑ Public ❑ Storage ❑ PublicWater <br /> ""An y e a rt h m o v e m e n t m a y r e q u j r�� ❑ C ommercia l ❑ Other(specify) <br /> MCWD review 8�permits. �KtS h .� ❑ Industrial ��/ <br /> Minnehaha Creek Watershed District.(MCWp r L"1 I'fivate Well <br /> 18202 Minnetonka Blvd C��,��Nlt=�j � Othef: (speCify) <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> Hnvw.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ ���Y1 Z` r� <br /> Last Updated: 9/29/2009 <br /> - 17- <br />