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� � So�?i <br /> �,����,� _ <br /> City of Orono l �' Jl � � � <br /> � <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> Q PO Box 66 Permit number: a���^6 <br /> �` �� Crystal Bay, MN 55323-0066 Date received: <br /> StreetAddiess�� ` Received by: <br /> y ,� 2750 Kelley Parkway Plan review fee: �� � � $Cj "�`j�-iy <br /> �' c,` Orono, MN 55356 Z o�y"��Z 9=-=.- �- , <br /> �'�kFSHo��' Main: 952-259-4600 Total Fee: <br /> 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: �,S ' <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes No <br /> If yes,a special event pem►it is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service w�ll <br /> required unless applicant demonstrates su�cient on-site paiking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLIC T INFORM TION: <br /> Name: <br /> State License# Expiration Date: <br /> Phone: cell � office � ,�- y '7 <br /> Mailing Address: S"�"•h ��y„ � � Cit : ZIP: ..� <br /> Contact Person: -...�. Ap licant is: o tracto / Homeowner (Circle One) <br /> Email and/or Fax: �; <br /> PROPERTY OWNER INFORMATION: <br /> Name: r'�L � �CG l�1�✓tt �f� C'�1V <br /> Phone (day): �, � z- �c�cj - Z,j � �,. <br /> Address: . c� . "�' u � - Cit :C r S�q� �Q ZIP:�J ��3 <br /> Email and/or Fax � o, �j-✓� <br /> ARCHITECT I ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of pro�ect: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal 8� <br /> Water Supply <br /> �'New Construction �'Single Family with Residence <br /> ❑Addition attached garage ❑ Garage/Accessory Bldg. Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Ot .t�r�. (specify) ❑ 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 Blvd <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> $ � <br /> Estimated Construction Valuation (excluding land) �j �j�fi �Q <br /> Padcet Last Updated: 04/19/2013 <br /> Page 22 of 23 <br />