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� City of Orono <br /> Building Permit Appiication <br /> for New Structures or Additions <br /> O MailiPO Box 66• Permit number: o�Ol a���S(o <br /> O� �vO Crystal Bay,MN 55323-0066 Date received: � �b�` Z <br /> � a St�et Address:' Received by: <br /> Gti�' 2750 Kelley Pa aY�.��� ��' Plan review fee: �g <br /> �.�o�,� Orono,MN 553 <br /> Totai Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be compteted in fuli and afl required information must be submitted. <br /> Incomplete applications will be returned. (PJease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 11� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a special ev�ent permit is required with Polioe Depa►tment and City Counal approva160 days prior b the e�rent. Shu bus senrice will be <br /> required unless applicant demonstretes sufficient on-site paricing is available. Non pe►mitted events wiH not be albinred. <br /> CONTRACTOR/A PUCANT INFO ATfON: � <br /> Name: ` � f ���i <br /> State License# �"/�d/� ,W�'� Expiration Date: <br /> Phone: �Z-1 '?�"�a�-��.�C� (office) �,5�—.Z�.2' L,�3�7� (cell) <br /> Mailing Address: � d2 '� p t� Ci : r� fi / ZIP: <br /> Contact Person: J�' �� Applicant is: n � / Homeowner �cir�ie ooe� <br /> Email and/or Fax: _,`��}(-���J 312 � f�� r CD YY1 / g.s� -�i2�%-3!��`� <br /> PROPERTY OWNER INFORMATION: <br /> Name: r17�1n �! SA'VtMa �C-�/1 S <br /> Phone(day): �,�t _��'�- S G l� <br /> Address: ��07 t� N D V'�-f� �1'1.b Y2 A 3' 1 V °� City: �j/�Oy, �, ZIP: 5�3 t f <br /> Email and/or Fax ��/i�-, ��o f �`S� @q�r,ai/, c e�� <br /> ARCHITECT/ENGINEER INFORMAT N: , . <br /> Name: ��'� 2 / "h� �C' /� �l�C <br /> Phone(day): . — — ' <br /> Address: � ,� '�;.� c '< � � � i�r Ci : ' ��,i , ZIP: <br /> Email and/or Fax: ��}�-(��C.-�f".� �� �. f�'Z'�L- : Ct�y� <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8 <br /> Water Supply <br /> ❑ �Vew Construction ;�Single Family wfth ' ence <br /> ddition attached garage ' arag /Accessory Bldg. �..Public Sewer <br /> ❑Accessory Building ❑ Single Family with <br /> � Relocation detached garage Office/Commercial ❑ Private Sewer <br /> Other. (specify) ��'I'�Cl�k ❑ Multiple Family!Condo ❑Warehouse <br /> ❑ Public ❑ Storage �Public Water <br /> "kAny earth movement may require ❑Commercial ❑ Other(specify) <br /> IIACWD review 8 permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) <br /> 18202 Minnetonka BNd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-�82 <br /> www m'n eh <br /> Estimated Construction Valuation (excluding land) � ��-�j GO f.� <br /> Padcet Last Updated: 03-06-2012 <br /> -21 - <br />