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<br /> . City of Orono
<br /> ���� �� Building Permit Application
<br /> . . � � 3�, �
<br /> for New Structures or Additions � �
<br /> Mailing Address: Permit number: c�/d '�ll
<br /> �g,O PO Box 66
<br /> ��Q � � Crystal Bay, MN 55323-0066 Date received: � � '� �0
<br /> `�p;�t�
<br /> (a 1�'���-�;' s, Street Address:� Received by:
<br /> � s ,�-
<br /> �',�, , ��`�'�,� �� 2750 Kelley Parkway Plan review fee:
<br /> t`�gESHo�''� Orono, MN 55356 �O _Q `/�� C�
<br /> - Total Fee: /)73�
<br /> Main: 952-249-4600 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 /> Jc�b Site Address: L�� � ���.i� - � .;,�, ���:1-� �'t �!��.�%,��� r���I,�:�;l,
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes ❑ Ivo
<br /> If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shu le bus service will be ,?�
<br /> required unless applicant demonstrates sufficient on-site parking rs available. Non-permrtted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: � , � �_ , �,_,�.;r`� .. < , ,•u� 1 ! '� ;-!t't��( �/� �_.
<br /> State License# �� �j q Z..� ?j Expiration Date:
<br /> Phone: =��'j z -�' � /�t G`. (office) �/� `j� � - ���'`� � (cell)
<br /> Mailing Address: c ' ic /%Ji//�-`� �Cti ,�-c � . _l • City: ��l-�jr�, ,/ ZIP: �S �� J �;,
<br /> ��!-" �
<br /> Contact Person: .��.�, �� ��lf, ��4.L.��:c,- Applicant is:�Contracfor_J Homeowner (Circle One)
<br /> Email and/or Fax: � f� � c� �`�, ���,/?� ��:f:=:�.•: � , � ; ;;, —
<br /> J�
<br /> PROPERTY OWNER INFORMATION:, �-
<br /> Name: �"_ /�/.��: ! �::. Y��� �j�✓�t'-dJ / L�C✓Ui�2-��7
<br /> Phone (day): � � i�,� � � ��:; t���� f �
<br /> Address: �,j l) S��.��.�,7 ,l�7" /�r C �� �� City: /�f�G�. ZIP: ,SS� �i
<br /> Email and/or Fax �2_� ���,;y�,�,y ,� �-- m�' . c�;x
<br /> ARCHITECT/ ENGINEER INFORMATION:
<br /> Name: ',i��r' r /i it � i���� �G7i/`r�C;=fll2f% � '"" �-
<br /> Phone (day): , ,_ �- �, 4- C` ,_
<br /> Address: -� -,�, � ��, . - �, iC- � ��. Cit : C:- �i� ZIP: -: � �' =� `/
<br /> Email and/or Fax: ."-F' " �- �',ylc� t��;«� �'L-i�
<br /> PROJECT INFORMATION:
<br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal &
<br /> • Water Supply
<br /> �],New Construction �Single Family with �Residence
<br /> ❑ Addition attached garage ❑ Garage/Accessory Bldg. ,� Public Sewer
<br /> ❑ Accessory Building ❑ Single Family with ❑ Deck
<br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer
<br /> ❑ Other. (specify) ❑ Multiple Family/Condo ❑War�use ^
<br /> ❑ Public ❑ Stora ❑ Public Water
<br /> *"Any earth movement may require ❑ Commercial ❑ OtheR•{s�ecif�'j
<br /> MCWD review&permits. ❑ Industrial �� �Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) `
<br /> 18202 Minnetonka Blvd /., l �
<br /> Deephzven, MN 55391 U
<br /> Phone: 952-471-0590 `� , �
<br /> Fax: 952-471-0682 `°-� / �,
<br /> www.minnehahacreek.or C -J
<br /> �
<br /> Estimated Construction Valuation (excluding land) $ � �.,��-i.% c�t-�_� � �`
<br /> ,�
<br /> Last Updated: 9/29/2009
<br /> - 17 - �
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