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. • <br /> 5 <br /> LI/q5 <br /> City of Orono l,IO Y <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: Permit number: C))0P—D aO03 <br /> 4-,. <br /> O4 Cr Box 66 /� //� Crystal Bay, MN 55323-0066 Date received: / <br /> ,.;s. 4i >, Street Address:' Received by: <br /> ii 1 cn s o`i 2750 Kelley Parkway Plan review fee: S420 ,�p9 <br /> . ,I • oQ� Orono,MN 55356 <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: <br /> Job Site Address: 810 O(rp G'r*.ST ., gPr 140..© <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: TOM") So,I'J -K / Ct1AA.J.%S CVRD De ►JoVC) <br /> State License# 2.065614V Expiration Date: / //3 /2013 <br /> Phone: 4;Z-$33-8 0 (office) 612.389- 3$30 (cell) <br /> Mailing Address: ;Soso 23 Alva N City:P1.YMoum ZIP: ICAO!7- <br /> Contact Person: SvrW SC1n1 64( Applicant is: 4•411r l'.7r / Homeowner (Circle One) <br /> Email and/or Fax: TSQNM ff,/( p C.PIAA.SSGt)bb.GANG <br /> PROPERTY OWNER INFORMATION: ` x , <br /> Name: * t1 YY <br /> bt 1t..6%AMo <br /> Phone(day): - - <br /> Address: it pc.otie4c 'i, Q Q. City: SP/a44)(,.irx ZIP: 77.3g2..., <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 IN 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 r Private Sewer <br /> ❑Other:(specify) ❑ Multiple Family/Condo ❑Warehouse <br /> ❑ Public ❑ Storage ❑ Public Water <br /> **Any earth movement may require ❑Commercial i Other(specify) <br /> MCWD review&permits. ❑ Industrial a .tika • 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.orq <br /> Estimated Construction Valuation(excluding land) $ id—2-8700a <br />