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t 1 <br /> City of Orono <br /> 1 � <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: —©/ <br /> Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: <br /> , ✓ <br /> Received by: <br /> Street Address:' <br /> \�� � •.9. Gti Kelley 2750 <br /> Y Parkwa Y Plan review fee: <br /> ly '" r� Orono, MN 55356 <br /> kQ40¢ aol�-G , <br /> Total Fee: <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 /> +12-5Job Site Address: N e h-SWK_ `VV <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: KA-rt4egztmG7 YLo6—"s 4eme:5 e, <br /> State License# If73S, Expiration Date: A sof <br /> Phone: X6'2- 14 7 3 - Soo (office) (cell) <br /> Mailing Address: PAIL-wA-? S- x 35- City: t�eQ&T'ro ZIP: 35-7 <br /> Contact Person: 6.00R i-,k4L--y 784LoV2 Applicant is: ontractor / Homeowner (circle One) <br /> Email and/or Fax: c_.j-Tisr to, ka.44ta.A�,,'nxL.4QW tars horn es cc-.-,... <br /> PROPERTY OWNER INFORMATION: <br /> Name: To1+r_l RD0Fy4F-t_ <br /> Phone (day): 7123_` L1 f_ 57 5-2- <br /> Address: 4-72-,5- Noa2Tt4 544eA2.E AFL• City: o,26&io ZIP: <br /> Email and/or Fax e>hvt a e-vie4nol. cower <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <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 t, ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached g ❑ <br /> arage ElOffice/Commercial El Private Sewer <br /> ❑ 17 <br /> Other: (specify) L�K f�Tf� El Multiple Family/Condo Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial ❑ Other(specify) <br /> MCWD review&permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) ❑Other: (specify) <br /> 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ 60400 <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />