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147-0 da 139 <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions $As/ " � <br /> Mailing Address: Permit number: vw/0—1700X0.2-1 <br /> (3.111Cr ,1-1/Bax 66 <br /> Crystal Bay, MN 55323-0066 Date received: 3 O <br /> Received by: <br /> A .-'':fig- a, Street Address:' <br /> Ir. o~ 2750 Kelley Parkway Plan review fee: 9. O n, <br /> `�kEssog Orono, MN 55356 ,--,0/e —066 V/ <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: p <br /> Job Site Address: / 0 30 6 l a Cn. 5 ttL �1 AclA /ZCt <br /> Will this be a Parade of Homes, Remodelers Showctise Home or othef Display Home? E Yes ,t 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 wilrbe <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: D Q R!5 i3 cOAcf- i..Lc_ David 8 . R45i • <br /> State License# 32/V/ Expiration Date: $e ✓ // <br /> Phone: 6/ z-9 6S- ?467 (office) 763 -417? -)5 3 cell) <br /> Mailing Address: ;... &/...,) crkd i„dtR, (i,Ve_ City: Teti/LA ZIP:, 533 j <br /> Contact Person: ,i) K A.5 kof Applicant is: Contractor / Homeowner (circle One) <br /> Email and/or Fax: db ray ko b & ynGGis i ,CO/VL <br /> PROPERTY OWNER 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 /> 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 /> .N Accessory Building ❑ Single Family with ❑ Deck <br /> Relocation detached garage ❑ Office/Commercial ❑ Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo El Warehouse <br /> ❑ Public El Storage ❑ Public Water <br /> **Any earth movement may require ❑ Commercial El Other(specify) <br /> MCWD review&permits. ❑ Industrial El 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 delwww.minnehahacreek.or. <br /> Estimated Construction Valuation (excluding land) $ OCO <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />