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City of Orono <br /> BuildingPermit Application <br /> / v59y' ,2, <br /> for New Structures or Additions <br /> Mailing Address: <br /> APermit number: 1 7-o , <br /> 0 ,. PO Box 66 <br /> .► `VQ Crystal Bay, MN 55323-0066 k Date received: 2 . -'f / 1 <br /> ` Street Address:' I3p` <br /> Received by: <br /> 2750 Kelley Parkway <br /> A <br /> `" r 4.E Orono, MN 55356 Plan review fee: <br /> f,26 ;20l�kFSHo�`� Main: 952-249-4600 Total Fee: 2017- 0(k>i33 <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 submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: :795-/__ ) 7 / 47A) <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus servi will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non permitted events will not be allowed. <br /> CONTRACTOR/APPL)CANT INFORMATION, <br /> Name: ,.,uv73u� (,�.a ,,c- ,4 �e% <br /> State License # 8,( Cod 6b Expiration Date: <br /> Phone: cell Ca "t v office ,,-/a -...S—/ <br /> Mailing Address: -,---, Q - Z� Cit : ,e0N0 <br /> Contact Person: <br /> ,5-w7 A'... c o.NJ, Applicant is: Contractor / omeowne (circle one) <br /> Email and/or Fax: Jc„„ -/ , e/ii. . C ----i <br /> PROPERTY OWNER INFORMATION: <br /> Name: 5(o', £ a.^) <br /> Phone (day): C,/0 ,4'4,- a VoS <br /> Address: 7cS 7--P1-,.,C( A'aA) City:6Z,Ov ZIP:;,S 3 9/ <br /> Email and/or Fax k,,,---t- / . <br /> ARCHITECT/ NGTER INFO MATION: <br /> Phone(day): , —_ , - e <br /> Address: 3 J ' c/ e So City: '"��l ZIP: SIS—V6 <br /> Email and/or Fax: f,,, <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: (A -A4 4 i-I-)`o J <br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4.Sewage Disposal& <br /> Water Supply New Construction 0 Single Familywith 0Accessory Bldg./Garage! 'ddition attached <br /> garage 0 Deck <br /> 0 Public Sewer'ccessory Building 0 Single Familywith ❑ Office/Commercial <br /> ❑ Relocation detached <br /> garage 0 Residence <br /> ❑ Septic❑ Other:(specify) 0 Multiple Family/Condo0Retaining Wall(s) <br /> (Compliance certificate <br /> 0 Public 4-feet or greater may be required) <br /> **Any earth movement may require 0 Commercial 0 Storage <br /> MCWD review&permits. 0 Industrial 0 Warehouse 0 Public Water <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 <br /> 0 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Estimated Construction Valuation (excluding land) $ /3'T /C <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />