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City of Orono <br /> Building Permit Application ; 09 <br /> for New Structures or Additions <br /> Mailing Address: Permit number: cvy (a 00 S�9 <br /> 0, PO Box 66 �_ <br /> Crystal Bay, MN 55323-0066 Date received: 9 �7 <br /> " Received by: t-0 <br /> a Street Address:' <br /> 2750 Kelley Parkway Plan review fee: Y`C. <br /> \ <br /> Orono, MN 55356 t�Eyggo �' � <br /> 1 <br /> I , <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us Total Fee: H <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: <br /> Will this be a Parade of Homes, Remodelers Showcase Horne 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 k1l 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: :V" n.,—r, Q - 4 ul,c� j �liiAECZ-a �V1 <br /> State License# R C- �v H K 32-o 3 Expiration Date: <br /> Phone: IgS - y rri office cell <br /> Mailing Address: 77�- S' c fi g«c C City: t21a-,-.C2IP: ;>el <br /> Contact Person: Tt-,,�>,,,,,4 Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: �„ .,,Q 4 e-- G,vI-„,«t, l . 6 c Y,, <br /> PROPERTY OWNER INFORMATION: <br /> Name: .i c, (t e V 2- c,k ear s/ <br /> Phone(day): C t)- -7 1 O- 7 cl i C <br /> Address: (�a�v��+�, ��_� jar w City:l?k`1/e-(>/A,4h 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 /> 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 5?1 Private Sewer <br /> Other: (specify) 0e c-L'- ❑ 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) $ �� )C/C/ <br />