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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> AlLo PO Box 66 Permit number: (7.Q 17_Ol L(o7 <br /> e► O Crystal Bay, MN 55323-0066 Date received: , <br /> Street Address:' i - 9 Received by: <br /> , . 2750 Kelley Parkway l <br /> 6F r G� Orono, MN 55356 Plan review fee: .5 17ti�- <br /> �'fkFsti01" Main: 952-249-4600 .2011-6176 <br /> 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) v 5C;C ; peA I R/7/17 <br /> GENERAL INFORMATION: X017,0114,I <br /> Job Site Address: -5Z(6(.. k1Aut en L,...) ,U ' vb....l. A-4.2) <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ViNo <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: .)L 1,k,= L �--).sa e_�.� /./J <br /> State License # CS(' +-12_90v95 Expiration Date: 'c j s t 106 <br /> Phone: (cell) (...•"s1---c _ 'St,Z7 (office) — <br /> Mailing Address: Za'14, .r.,,y" per , City: ,, ZIP: 553113 <br /> Contact Person: Z_..,Aa --7.--CF-,,NdApplicant is: , ontractor]/ Homeowner (Circle one) <br /> Email and/or Fax: c I L,1 cloy. .f., 4v-,...,__N-I C" ca. <br /> PROPERTY OWNER INFORMATION: <br /> Name: (..--17-0-..c...+v k-_ ,ANa-k.-iir-3 ta4.-3 -..-J <br /> Phone(day): TLL1 Syv -0-1,.11 <br /> Address: ;7t6L tJau.e.sw- L City: OL01,10 ZIP: <br /> Email and/or Fax `(rx(,,kc 4 ;1. tx,.,,, <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: 1-F'-P. bc.,�<,i <br /> Phone(day): '1c�3 - 'MO - $.1-c <br /> Address: '‘ID( t..1 ..0., S1 kg SL��k- lDL. City: c ZIP: 4L1� <br /> Email and/or Fax: h�,0 Dc p (s z , <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 /> New Construction Sin le Familywith Water Supply <br /> Addition g ❑ Accessory Bldg./Garage <br /> attached garage ❑ Deck 0 Public Sewer <br /> ❑Accessory Building 0 Single Family with Office/Commercial <br /> ❑ Relocation detached garage Residence <br /> ❑ Septic❑ Other:(specify) 0 Multiple Family/Condo Retaining Wall(s) <br /> (Compliance certificate <br /> ❑ 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 0 Public Water <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) ❑ Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 <br /> 0 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.m innehaha creek.orq <br /> Estimated Construction Valuation (excluding land) $ PS50 i ( - <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />