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<br /> CITY OF ORONO -\kms
<br /> BUILDING PERMIT APPLICATION
<br /> fAcr i 1:4e-/
<br /> FOR NEW STRUCTURES OR ADDITIONS Q
<br /> % 0 Mailing Address: Permit number: c201p—00
<br /> PO Box 66
<br /> O Crystal Bay, MN 55323-0066, Date received: 1 Zi7
<br /> Received by: i
<br /> A ,, Street Address: (.
<br /> s� G� 2750 Kelley Parkway?/ �lo Plan review fee: .v 3/? 57
<br /> `4kfs 110' Orono, MN 55356 ��I h �o(F cO/041
<br /> Main: 952-249-4600 Total Fee:
<br /> Fax: 952-249-4616 www.ci.orono.mn.us
<br /> This application form must be completed in full and all required information must be subnd. _
<br /> Incomplete applications will be returned. (Please print) -WC ICI 5j, 7.1I*
<br /> GENERAL INFORMATION:
<br /> Job Site Address: r_5`-‘ (-3 lc) tL...D , c,2 c- ,.tiv 5 5 - I
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 14 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: -F(gw ., wX-rliv\e-t .'�.
<br /> State License# Expiration Date:
<br /> Phone: (cell) ' ti\ct) (Ay �;5 4. V (office) (_`‘cL) ZZ; sI IC.)
<br /> Mailing Address: 2 .;k L,,, Pr-,t-t--i-A C;.'-i•--( e_.0 City: Ex c_u_skc2 ZIP: Ss-3 3
<br /> Contact Person: Applicant is: Contractor / (Homeown (circle one)
<br /> Email and/or Fax:
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: S}1.' .s wSc..t-tME_ Z
<br /> Phone(day): Ccl (-1y - r,?,`is,`+
<br /> Address: zt, ‘ c.,�,ri\:,++-rA 3,^i-r iyo City: Evcec,-,t., ZIP: --�3 31
<br /> Email and/or Fax ---s,,�,.;', c\,(Y\ e N Q-4- Cy,n.4.;,\. c .
<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: AN E >:., LLA c;-.-c- ,,&E u_.c cc c)Q-5 k.L%.,S , L_L-c_,
<br /> Phone(day): L"1-e L) 7 1 c.:'-65
<br /> Address: 9 �-,2. V.tit( __E 5 City:,n,is.i.,E:A;>(.,:_-s ZIP: C c --t x9
<br /> Email and/or Fax: ,,\ k X11`,0 ti" 9 4 L +,.,,,-,\, c_,,„
<br /> PROJECT INFORMATION: Description of project: C; c‘ Acs E ADOC M c,
<br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal&
<br /> Water Supply
<br /> ❑ New Construction ❑ Single Family with ®Accessory Bldg./Garage
<br /> ❑Addition attached garage ❑ Deck ❑ Public Sewer
<br /> ®Accessory Building Z Single Family with ❑ Office/Commercial
<br /> ❑ Relocation detached garage ❑ Residence © Private Sewer
<br /> ❑Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s)
<br /> ❑ Public 4-feet or greater ❑ Public Water
<br /> **Any earth movement may also require ❑Commercial ❑ Storage
<br /> MCWD review&permits. ❑ Industrial ['Warehouse 'Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ❑ Other(specify)
<br /> 15320 Minnetonka Blvd
<br /> Minnetonka, MN 55345
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.org
<br /> Estimated Construction Valuation (excluding land) $ =;Ls i o c:c>
<br /> Last Updated: January 2016
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