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C�ty a� �ron� <br /> . � �uildin� R�r��� A���icatian <br /> for t�evv Str�ct�res or elditi��s <br /> Mailing Address: <br /> ���j PO Box 66 � (�i� Permit number: ocb/7-D�p 2`�-J <br /> � Crystal Bay, MN 55323-00 � � <br /> Date received: �� $-�'7 <br /> Street Address:' � I n� Received by: /�/� <br /> y G��C'' 2750 Kelley Parkway Q W � 2�/ �/ <br /> `�t,� �, Orono, MN 55356 J Plan review fee: �� � ���- <br /> xESHo�` Main: 952-249-4600 Total Fee: �d�� d!O 2�� <br /> Fax: 952-249-4616 www.ci.orono.mn.us l ,/ <br /> This application forrrt must be completed in full and all required information must be submitted. <br /> Incomplete applications wiil be returned. (P/ease print) <br /> GENERAL INFORMATION: <br /> Job Site Address: �t��(� /�,,��,,-f;, �`���,_�., _ rs V� <br /> Wiil this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes No <br /> If yes,a specia/event permit is requi�ed with Po/ice Department and City Council approva/60 days prior to the event. Shutt/e bus service wi1/be <br /> required unless applicant demonstrates sufficient on-site parking is availab/e. Non�ermitted evenfs will not be a!lowed. <br /> CONTRACTOR/APPLI�ANT INFORM TION: <br /> Name: ��'►� ' ..� .h �-� c�� �.-l.L <br /> State License # C 3 Expiration Date: 3 -31- 2v i� <br /> Phone: cell 9 5"2-- 3— _S3-� office <br /> Mailing Address: '��� / " Cit : �u„ ZIP: <br /> Contact Person: � �- c�„� ,,,t a, Appiicant is: ontractor Homeowner + <br /> Email and/or Fax: �a , �, � � G,.+,, f,� a �G (Circle One) <br /> PROPERTY OWNER INFORMATION: <br /> Name: ��t� { 'S-��n���er S�,�n�� �r�� f <br /> Phone(day): y5 Z �7 ? '�( 3� <br /> Address: � o i+.�� t�� 5��.�c l�.-�e Ci : ��-�.� ZIP: .5-53L-¢ <br /> Email and/or Fax � `, .'� wti rZ ✓� ,� ;w C�%< <�„-� <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: Cit : Z�P. <br /> Emaii and/or Fax: <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: C�t : Z�P. <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Descri tion of pro"ect: ��.,v�� E c�.�z�L� ��,,,,�� -}� �_,�,.U�;;,� <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal& <br /> ❑ New Gonstruction Water Supply <br /> ,�Single Family with ❑ Accessory Bldg./Garage <br /> J�'Addition attached garage ❑ Deck <br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial �Public Sewer <br /> � Relocation detached ara e <br /> I5� Other. s eci �i'b 17 9 9 C� Residence <br /> 1�► t P �� `S ��%� ❑ Multiple Family/Condo ❑ Retainin Wall s ❑ Septic <br /> 9 ( ) (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 /> Minnehaha Creek Watershed District(MCWD) ❑ Public Water <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 � �her. (speCify) ❑ Other(speCify) <br /> Phone: 952-471-0590 / Fax: 952-471-0682 �Private Well <br /> www.m innehahacreelc_oro <br /> Estimated Construction Valuation (excluding land) $ ,��� ��:,�.� <br /> Packet Last Updated.• January 2016 <br /> Paqe 21 <br />