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. , ,� G�ty of O�ono <br /> B�ilc�ing Pern�it �p�lication <br /> for �tew �tructures or �►dditions <br /> Mailing Address: <br /> �Q� PO Box 66 Permit number: <br /> � Crystal Bay, MN 55323-0066 Date received: <br /> Street Address:' Received by: <br /> y ,� 2750 Kelley Parkway Plan review fee: <br /> �' L� Orono, MN 55356 <br /> l�KfSH��� Main: 952-249-4600 Total Fee: <br /> Fax: 952-249-4616 �v�✓v;-.ci.orono.mn.us <br /> This app{ication form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: _ � (y�p /�n�� 5��,.���, <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 Counci!approval 60 days prior to the event. Shutt/e bus service will be <br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: S�p�M�,.o �X'�*c�:o�s rn� <br /> State License # �C 4 3 S Expiration Date: 3- j�.- �� <br /> Phone: cell 6 r z � ?8 office `1Sz S r 3 • �66 <br /> Mailing Address: c� , e 2 r8 Cit : �� ZIP: SS3 6 <br /> Contact Person: �QS o.�. Ba.-. Applicant is: ontractor / Homeowner (Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMATION: <br /> Name: Tc d 1�.1 c�,� <br /> Phone (day): �2 S • S o <br /> Address: y�yn lU _ $ho+�t �r. City: Q re.�o ZIP' SS31r�l <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP� <br /> Email and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: Z�p• <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: � - Root' <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> ❑ New Construction Water Supply <br /> ❑ Single Family with ❑ Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Sin le Famil with ❑ Public Sewer <br /> g y ❑ Office/Commercial <br /> ❑ Relocation detached garage ❑ Residence ❑ Septic <br /> ❑ Other: (specify) � ❑ Multiple Family/Condo ❑ Retaining Wall(s) (Compliance certificate <br /> ❑ Public 4-feet or greater may be required) <br /> **Any earth movement may require ❑ Commercial ❑ Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse <br /> ❑ Public Water <br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Othe�(speCify) <br /> 15320 Minnetonka Blvd; Minnetonka, MN 55345 ❑ Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-�682 <br /> www.minnehahacreek.oro <br /> Estimated Construction Valuation (excluding land) $ /� o 0 0 ."� <br /> --� <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />