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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: -00 <br /> O�,0,�0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: r' <br /> Street Address:' Received by: <br /> 2750 Kelley Parkway Plan review fee: 70 <br /> Esx0 Orono, MN 55356 ter„ _1-1�10 <br /> Total Fee- /a D � 0u <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 m t be submitted. <br /> Incomplete applications will be returned. (Please print) ' GII� 1748bZ <br /> GENERAL INFORMATION: <br /> Job Site Address: (OS o1A cl�jsf -] Y-�,_, e.,J <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: c7 /�� ��.� .5cL/' <br /> & S <br /> State License# <br /> Phone: gy2 C (cell) <br /> Mailing Address: � �_4 <br /> Contact Person: c c (Circle one) <br /> Email and/or Fax: , <br /> PROPERTY OWNER INFORMATION: <br /> Name: 0_A2A 62 Pu L 1%t, c L 13 <br /> Phone (day): cKe -__"(f- 93Lq4 <br /> Address: 6 fS__ c)l .,a' s/a / 417T; <br /> "` \ <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER I �FORMATION: <br /> Name: <br /> Phone (day): <br /> Address: <br /> Email and/or Fax: <br /> L,. <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 ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial Other(specify) <br /> MCWD review&permits. Industrial 6,01. �� 1��•c �. ElPrivate Well <br /> Minnehaha Creek Watershed District(MCWD) Other: (specify) T- <br /> 18202 Minnetonka Blvd CAA- 4)Qi,, <br /> Deephaven,MN 55391 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.or <br /> Estimated Construction Valuation (excluding land) $ *V S <br /> Packet Last Updated: 03-06-2012 <br /> -21 - <br />