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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: . 11-- , 04.?11 <br /> �T PO Box 66 <br /> VO Crystal Bay, MN 55323-0066 Date received: /- '1 <br /> Street Address:' t� Received by: <br /> -X//1,(3 <br /> 2750 Kelley Parkway `\` <br /> Plan review fee:� <br /> tis? <br /> Orono, MN 55356 I , 495.k SHO* Main. 952-249-4600 Total Fee: 7/ <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: ^-; c\ 5 S 1&-e.„r(1 <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 Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: A+\o.S (-\O M.L 4 <br /> State License# Q £ 2-0'1 (o 9 (d Expiration Date: o`f / it <br /> Phone: (cell) ' 6 3 6 cx t Oct 1 (office) to-3 H ZS 333 3 <br /> Mailing Address: 19' s O I 1 7 i-- A-,,.e, A) City: A-luQ le L• ;,+.e... ZIP: '-5. 3 6y <br /> Contact Person: /1.1 k- t.t)(AN( Applicant is: Contractor / Homeowner (Circle one) <br /> Email and/or Fax: „AN,.t-C c).--\AK h o„ik,e5 fryik , co./A <br /> PROPERTY OWNER INFORMATIQN: <br /> Name: 1 °4(A d- �V(A. ( t4vo <br /> Phone (day): <br /> Address: City: ZIP: <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: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction <br /> 0 Single Family with 0 Accessory Bldg./Garage <br /> ❑Addition attached garage 0 Deck <br /> 0 Public Sewer Accessory Building 0 Single Familywith ❑ Ofce/Commercial <br /> ❑ Relocation . detached garage ® Residence 0 Septic <br /> Other:(specify) 1--/-,/ RLPtif5 0 Multiple Family/Condo 0 Retaining Wall(s) (Compliance certificate <br /> 0 Public 4-feet or greater may be required) <br /> "Any earth movement may require 0 Commercial 0 Storage <br /> MCWD review&permits. 0 Industrial 0 Warehouse <br /> 0 Public Water <br /> Minnehaha Creek Watershed District(MCWD) p Othgr:Apecify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 - <J sr t'.i S r ri 0 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 J <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $(0& e0 O - Q 2 pA 1'C' Wew- 0 vi l y <br /> Packet Last Updated: January 2016 ✓ / <br /> Page 21 <br />