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. City of Orono <br /> Building Permit Application , 1 <br /> for New Structures or Additions 73 I' �� <br /> Mailing Address: Permit number: �J/7 - 0/(a/0 <br /> sLQAr PO Box 66 <br /> W Crystal Bay, MN 55323-0066 _�/t , Date received: /e-8'17 <br /> Street Address:' /�J`,'\�- Received by: <br /> t 2750 Kelley Parkway <br /> S elan review fee: $ / 7( S (G7 <br /> '�ESHo� Main: on 249-46006 \�'\,w tJ a0/17" c,/10129 <br /> Total Fe <br /> Fax: 952-249-4616 www.ci.orono.mnis p /`]-(J/(p// L`SCrvyt/ <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: 36 s 1, -e.ev.., r(\tzkw' , <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: (s*A,,.1 t A I4M <br /> State License# l ( 002,4S1 Expiration Date: , <br /> Phone: (cell) I Z 146 6 0 4 (office) '}z 5 i 37 45 a <br /> Mailing Address: t POO 8Pditif Jerve 1J.J City: S ZIP: 'c'`t 7.7 <br /> Contact Person: /vim � i rt_1�� Applicant is: Co rac r / Homeowner (Circle One) <br /> Email and/or Fax: tU M 1 dt i:1� CSG ut E A- ,,y1 is C6 ty <br /> PROPERTY OWNER INFORMATION: <br /> Name: o N`.1 CA, 4.„,14. n <br /> Phone (day): 5e: ,jRcvc J 5 n <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARC IIECT/ENGINEER INFORMATION: <br /> Name. �"? t.'ki y t.4 l t^. <br /> Phone (day): S 4y,it IWO Yf <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> ARCHITECT I ENINER INFORMATION: <br /> Name: �`�� nI- ASeLlATI <br /> Phone (day): CC 1 6 fvOl 41 r-- -÷-z I <br /> Address: 'i- -3 1\11Lui > r—D 104t'- City: t*t&At%) ZIP: SC -- <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 /> Ri New Construction 2 Single Family with 0 Accessory Bldg./Garage <br /> Addition attached garage 0 Deck <br /> Building ❑ Public Sewer <br /> ❑Accessory 0Single Family with 0Office/Commercial <br /> ❑ Relocation detached garage 0 Residence E Septic <br /> ❑ Other: (specify) 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) 0 Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 r3 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ 35c. co 0 <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />