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City of Orono � a3�, �S <br /> Buildin Permit A lication °�� <br /> 9 pp <br /> for New Structures or Additions �A�o2-c � <br /> Mailing Add�ss: �J/a ' U(�j S <br /> O��,�.0 PO Box 66 Permit number: <br /> � <br /> Crystal Bay, MN 55323-0066 Date received: ( �o�.-�� /a <br /> a ���� �, StreetAddress:' --- Recei � <br /> �',�, � �•��-.-; Gti�' 2750 Kelley Park y ��' Z Cr Plan review fee: �,/ `S� <br /> r�kESH04'� Orono, MN 55356 �� �. ' � % <br /> — Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono rnn.us �� (� -j0 -0�, <br /> This applic�tion 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: �So2Cj j'�/ �)j�- � r i/� <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> !f yes,a special event permit is required with Pofice Depariment and City Councif approva160 days prior to the event. Shutt e bus service witl be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be a/lowed. <br /> CONTRACTOR/A PLICANT INFO ATION: <br /> Name: � � �i p � //�� <br /> State License# �lj��S` Expiration Date: <br /> Phone: �sa =�ff-�!v.(%C� (office) ����`j�' r, 3�?�' (cell) <br /> Mailing Address: �` � � �- ' L .Z� <"� ��+ 'D C� Cit : ' ,� � / ZIP: <br /> Contact Person: �j�� ` «�,r-� Applicant is: ntr / Homeowner (Circle One) <br /> Email and/or Fax: ��p��,C�i �.N 3 �2 C� �c� . C�� / l�� -�.1�/- �la�`%` <br /> PROPERTY OWNER INFORMATION: <br /> Name: (U�In �! 1G1'yt{'t�{ �C-f�l S <br /> Phone(day): ���.- 7�� - �,��;, � <br /> Address: .���7 Z� /�j p►-}� �h�►'� {J:- i V f' City: ��v�+y��,, ZIP: 5�3`Y/ <br /> Email and/or Fax ��R,/,,.,_Dn t �r'S� GC�rr�ai/. �'v.+� <br /> ARCHITECT/ENGINEER INFORMATj�ON: //'C <br /> Name: ,��c'G c� t " r'7�c ' /il �C� /ns� <br /> Phone(day): - ,� _ -�'� <br /> Address: ;J�'l'� ��S ' ,.� i '.� � � � ic>�' Cit : �'� , ZIP: �" " -� . <br /> Email and/or Fax: �j r'� (�("�� �,+ 3„ � �J-L��- : C t�i�-�7 <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 with ' 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) hE'f��!G�«.l I ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage �Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review 8�permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) <br /> 18202 Minnetonka Btvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) � r�y 3, bD C> <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />