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� � � � � �� �� <br /> city of orono C�G <br /> Building Permit Application <br /> for New Structures or Additions V� �fi ' (�/ lt•1g•lt. <br /> �O� MailiPO Bo�r66 � Permit number: ���Q;���.�_ T i <br /> � O Crystal Bay, MN 55323-0066 Date received: Q-� —/� <br /> ,� ` ; �, StreetAddress:' Receivedby: �/►'1� <br /> �`,�, '� 6� �titi 2750 Kelley Parkway Plan review fee: gg�• <br /> ��ESHo�`'� Orono, MN 55356 ��o�-b/b S3 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us �' �,,� ; a��� � ?_�jp� � �C�-I L <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: j��� �ee�r^�`1 .S�CJ�� �f��'� ��U/�v � /��� ��� �� <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 prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events wrll not be allowed. <br /> CONTRACTOR/APPLICANT INFORMAT ON: Z <br /> Name: c, SU•^� �U��L U /Ir��jv�" ����U�,�l �d/l� <br /> State License# � C.� Expiration Date� i <br /> Phone: � office / �,.,$�i� cell <br /> Mailing Address: O ` u� Cit : ZIP: <br /> Contact Person: u tll�.� Applicant is: n c or / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: S�h��3i�-e,il �A��C. GLtC,r' . <br /> Phone (day): (��a 3�y �i � <br /> Address: p o S �.- Cit :LSR.o,R,D ZIP: ;���g � <br /> Email and/or Fax ��g����(� , Gc>�v'l LIC�b��I ���� JQV�iCaC,(�"��`i-�� <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: � �v f��� <br /> Phone (day): ���d �� Q � <br /> Address: � '� � �/�/ ZIP:��� <br /> Email and/or Fax: ,J � C r✓1 <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 /> ddition attached garage ❑ Garage/Accessory Bldg. �ublic 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 �ublic 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) $ ! =� , GiJv <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />