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City of Orono � �,�iD <br /> � <br /> Buiiding Permit Application <br /> " for New Structures or Additions <br /> Mailing Address: �r Q/b- <br /> 'g 0.� PO Box 66 Permit number: Q��` � <br /> � �� 0 Crystal Bay, MN 55323-0066 Date received: z �l <br /> �6 <br /> � ����-++" �, Received b � <br /> e::>w StreetAddress:' Y� L.�T <br /> �„�� <br /> � , y�"�.�, �� 2750 Kelley Parkway Plan review fe � <br /> t'�xEsxo4`'� Orono, MN 55356 Q�7 <br /> Total Fee: PT»���� /� <br /> Main: 952 249-4600 Fax: 952-249-4616 www.ci.orono.mn.us (v <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 /> l�� <br /> Job Site Address: 5 LG%�% �(� Y��I(/V� �Y1 1,�J <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 approva!60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted evenfs will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATIQN: <br /> Name: �rS �" � �'U1i c�C�1 C� <br /> State License# Expiration Date: 3 3 j �d <br /> Phone: G S Z� `t 4 — �{- �p Z (office) � Z — ��( 7 - �j (�(� � (cefl) <br /> Mailing Address: � G s� S � Cit : ZIP: <br /> Contact Person: .S�Y �<,. Appficant is: ontractor Homeowner (Circle One) <br /> Emaif and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: �iP+(�AY !=� �--�/� ��� <br /> Phone (day): 7�j�— � _ � <br /> Address: ���� /�(�. �-.Z. �Y' Citv� C..3�cirtb ZIP� �� � � (�� <br /> Email and/or Fax <br /> ARCHfTECT/ ENGINEER II�FORMATI N: <br /> Name: � U fv vnn � �S f , <br /> Phone (day): �J'S Z _ � 7 3 � 3i <br /> Address: / G1 `f Z� ��-�h i �-� !-+i� C�-i1C� Cit ' ����� �!f-�lrC ZIP� �J�C�I� <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 /> ❑ Addifion attached ara e <br /> ❑ Accesso Buildin 9 g ❑ Garage/Accessory Bldg. [�ublic Sewer <br /> rY 9 �'`��s� ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached ara e <br /> 9 9 ❑ Office/Commercial ❑ Private Sewer <br /> �ther. (specify) �c.lc� C{cHYn2/' ❑ Multiple Family/Condo ❑Warehouse <br /> L�����Pc- d��%v (��c�'=1� f(�C ❑ Public ❑ Storage ❑ Public Water <br /> �"Any earth movement may requjre�� ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. �:XrSh ,� ❑ Industrial �ivate Well <br /> Minnehaha Creek Watershed District(MCl/yg� ❑ Other. (specify) <br /> 18202 Minnetonka Blvd ('(L� Y�� <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ �3�1��. �= <br /> Last Updated: 9/29/2009 <br /> - 17- <br />