2012-01244 - adv plan review - Laserfiche WebLink

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� , City of Orono Building Permit Application for New Structures or Additions Mailing Address: �/'�0.� PO Box 66 Permit number: p�� —Q/ .v , \ Crystal Bay, MN 55323-0066 Date received: � �Y,. e� �� ' ��'=,.. ��, StreetAddress:' Received by:- --- __.__�_._ `� �lr:� �; ...._e_�_ . __ ��;�,��,��,�,�� 2750 Kelley Parkw � , � Pfan review fee: C 'Y�sxo4`j Orono, MN 5535 r.f'��i(t�- i,��2 Z' • � ---_' t�a�-Fe : — ! aZ� _-�'`' Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (P/ease print) GENERAL INFORMATION: Job Site Address: ��,L.r� ��,�.� �� -�Y -� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No /f yes, a specia/event permit is required with Po/ice Department and City Council approva/60 days pnor to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted evenfs will not be allowed. CONTRACTOR/APPLICANT INFORMATION: Name: . � Y�� t— r � � v`c.� State License# � . �� ° 3� Expiration Date: ��(�� -'� Phone: �� -,.7,_ � _�"- office '�. 3— ��4,. � � cell Mailing Address: � � - • � � Cit � � ZIP: Contact Person: L c�..� Applicant is: Contractor ` / Homeowner (Circle One) Email and/or Fax: �,,,1��„��y�C��.�4, . �.�hv�a,,-� +��^�,�.°� � �.-m-�-> � PROPERTY OWNER INFORMATION: Name: lk.�',�v t��.�t�� Phone (day): ( �,�-z� c�� _�-�-�—� Address: �/�:"" :�.�E�rz �� i N� Citv.�i_�. t��N��c z ZIP �,«, -�c Email andlor Fax �-7c,.�l y Z�( cS� � ARCHITECT/ENGINEER INFORMATION: Name: Phone (day): Address: Cit : ZIP: Email and/or Fax: PROJECT INFORMATION: 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal 8� New Construction Water Supply �Single Family with Residence Addition attached garage �Garage/Accessory Bldg. ❑ Public Sewer ❑Accessory Building ❑ Single Family with ❑ Deck ❑ Relocation detached ara e ❑ Other: (specify) 9 9 ❑ Office/Commercial ❑ Private Sewer ❑ Multiple Family/Condo ❑Warehouse ❑ Public ❑ Storage ❑ Public Water ""`Any earth movement may require ❑ Commercial ❑ Other(specify) MCWD review&permits. ❑ Industrial Minnehaha Creek Watershed District(MCWD) ❑ Private Well 18202 Minnetonka Blvd ❑ Othef: (speCify) Deephaven, MN 55391 Phone: 952-471-0590 Fax: 952-471-0682 www.minnehahacreek.or Estimated Construction Valuation (excluding land) $ ��.�� (:.0 �_.