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<br /> City of Orono 't
<br /> Building Permit Application �` g k
<br /> for New Structures or Additions �9 �u /\
<br /> Permit number: �//- 0/
<br /> 10(
<br /> Mailing Address: ��
<br /> (‘--3L;c;
<br /> O\ CrO Box 66
<br /> _- \ Crystal Bay, MN 55323-0066 Date received: //' -c21 -//
<br /> I. `__ Received
<br /> ,. Street Address:' by:
<br /> 'O
<br /> �.�' 2750 Kelley Parkway Plan review fee: 2 //-O/���
<br /> \qgotOrono, MN 55356
<br /> --, Total Fee: L'- i/
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us / ,i 1
<br /> This application form must be completed in full and all required information must be submitted. rx j 2e.i.. L
<br /> Incomplete applications will be returned. (Please print) q -k,(3'A2-
<br /> GENERAL INFORMATION:
<br /> Job Site Address: 505 S O.L. (X yS%31L /39y X,.0, D/-�O/v 2 2�I2 �
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? El Yes $ No 'A/i'i,Vll�.i
<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. TAW
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: /2,g / 0 /7/AR/2 -57/VA/
<br /> State License# — Expiration Date: —
<br /> Phone: 9,5 -Yo y- 07„, d(office) y -360 - 666-y (cell)
<br /> Mailing Address: ,..5- ....4-- S- obi ewyJ7 g, y .4r7 City: _Z.oWG- //gb �.
<br /> 6ZIP: 5.3._
<br /> Contact Person: /29///e, h'9,4i-,74Am/ Applicant is: Contractor / me (circle one)
<br /> Email and/or Fax: 27,,,9vE.,y,9,Q,,n,57iwil,4'Q GrJ,E J 7-, A./.. -7-
<br /> PROPERTY
<br /> /ETPROPERTY OWNER INFORMATION:
<br /> Name: ,D, i!i//J 4 Ifl,9///f/
<br /> Phone(day): 763—3(o -- ,(6‘V
<br /> Address: 5OS .0..4. ' G,- yy7-9L g..9y .e , City:.4°Aro. .4,9/7-A= ZIP: _516-3'
<br /> Email and/or Fax ,2g„.•z ,g4i72AN,V a) Q 2- s7. ,1/4-T
<br /> ARCHITECT/ENGINEER INFORMATION:
<br /> Name: 6- /-{DLO 5'?D 7,17/ER( //a vi.'I�f
<br /> Phone(day): 94--a -78- Y,
<br /> Address: ioo 1g DX 8, /5/09 5 "??.1./A/ ST City:,/i4, )°,4?,96.0e ZIP: 5-6'0 Z/
<br /> Email and/or Fax: 95-a - 758 -9.070
<br /> PROJECT INFORMATION:
<br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal&
<br /> Water Supply
<br /> ❑New Construction 0 Single Family with 0 Residence /)/
<br /> ❑Addition attached garage ,i Garage/Accessory Bldg. 0 Public Sewer
<br /> !Accessory Building 0 Single Family with 0 Deck
<br /> !Accessory
<br /> detached garage 0 Office/Commercial 0 Private Sewer
<br /> ❑Other:(specify) 0 Multiple Family/Condo 0 Warehouse
<br /> 0 Public 0 Storage 0 Public Water
<br /> '*Any earth movement may require 0 Commercial 0 Other(specify)
<br /> MCWD review&permits. 0 Industrial 0 Private Well
<br /> Minnehaha Creek Watershed District(MCWD) 0 Other:(specify)
<br /> 18202 Minnetonka Blvd AT r.4c/!50 6-944G
<br /> Deephaven,MN 55391
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.orq
<br /> Estimated Construction Valuation(excluding land) $ 5/9i DO 0
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