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City of Orono
<br /> uiidin Permit Application
<br /> ,
<br /> for New Structures or Additions
<br /> Mailing Address:
<br /> Permit number:
<br /> �� PO Box 66 e3)10 l7-�/D�'�
<br /> 0 Crystal Bay, MN 55323-0066 _ Date received: 9-?-17
<br /> Street Address:' I,� Received by: VW- N 'r LS
<br /> I'll, 2750 Kelley Parkway ').1I
<br /> � V' �� Orono, MN 55356 �� Plan review fee:
<br /> ,sHO Main: 952-249-4600 Total Fee: /
<br /> Fax: 952-249-4616 www.ci.orono.mn.us /� D/
<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: „ _4.1
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 11 No
<br /> /f 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: Dei-ic_S tt11 rA-( .''
<br /> State License # r'c 6,)`)/_S-15-
<br /> Expiration Date: . 3-3'0__%
<br /> Phone: (cell) b ) _5i 9 -c' '°. . (office)
<br /> Mailing Address: ,$ c 5-,-.1 s r £ Cit : r( ZIP: S 3''3) /
<br /> Applicant is: ontractor '/ Homeowner
<br /> Email and/or Fax: 1,).- ,:z,.-;,ei ,a y� h 1,,, C c,4.1. (Circle One)
<br /> Contact Person: R(2..,,,..A ,' Wit-.,,-z
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: ) ':,r' 11i,-,. aNce K
<br /> Phone (day): /L /)- -5'd 5” -- 5:5 G c
<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 /> •
<br /> Email and/or Fax: G
<br /> %) c x.s ;Tr, -
<br /> PROJECT INFORMATION: Description of project: 1:-,.,,,,1,,i O,-t,< / .4';,. ,J ,�,,_.- Y c,-'- ,ti,.
<br /> 1.Type of Project 2. Proposed Use 3. Structure Type yP 4.Sewage Disposal&
<br /> ❑ New Construction IDSingle Family with • Accessory Bldg./Garage Water Supply
<br /> ❑Addition attached garage e`seck
<br /> ❑Accessory Building 0 Single Familywith ❑ Public Sewer
<br /> ❑ Relocation g ❑ Office/Commercial
<br /> detached garage 0 Residence
<br /> ❑ Other: (specify) ❑ Multiple Family/Condo ID Septic
<br /> P 0Retaining 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. ❑ industrial 0 Warehouse
<br /> Minnehaha Creek Watershed District(MCWD) ❑ Public Water
<br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 0Other: (specify) ❑ Other(specify)
<br /> Phone: 952-471-0590 / Fax: 952-471-0682 CI Private Well
<br /> www.minnehahacreek.o c
<br /> Estimated Construction Valuation (excluding land) $ y(), e t, .j
<br /> Packet Last Updated: January 2016
<br /> Page 21
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