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'IOW <br /> City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: �D/, <br /> �T PO Box 66 Permit number: 7��3� <br /> �Of VQ Crystal Bay, MN 553230066 Date received: //- .7-47 -1`/ <br /> Street Address:' Received by: i T- <br /> 2750 Kelley Parkway �__—.. <br /> y� � �Plan review fee: X2/:7151------ <br /> , <br /> c` Orono, MN 55356 <br /> �1kesxov-f' Main: 952-259-4600 Total Fee: -_/3T_`- <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 submit'id. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: 1 <br /> Job Site Address: 96D 01-6LI1JC7 ,( KE Pc ) l 2 cd /Nti 553" <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Dislay Home'? ❑ Yes 3 o <br /> If yes,a special event permit is required with Police Department and City Council approval 60 day prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permi**- '-vents will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: <br /> Name: Sckt,Lc r'7 • ,L� <br /> State License# gC ;P „ Expiration Date: 373//P 0/G <br /> Phone: (cell) (Q/2- 3 (e-gq4/3 rt' (office) 95. -976 - 7(0.' <br /> Mailing Address: clic) Il'l t Qnr oakct /lye S .,rife „20y <br /> o of Cit : f. z cj ZIP: 5539/ <br /> Contact Person: kart Se r.JQ.rz Applicant is: ontracto ' / Homeowner (Circle One) <br /> Email and/or Fax: . rt @) 5Cki.Jcl_rZ-11 lrs . Co n'l <br /> PROPERTY OWNER INFORMATION: <br /> Name: r j.rjst kr !e otlr C fl ski <br /> Phone (day): S - 3 5-.2S-00 <br /> Address: 4/55 old. L.ovi . � o{ City: L�)a(i-ze. c ZIP: 553'' <br /> Email and/or Fax c; 1;e_i nski ) IInc./..a.4b10 iss ,C o ryt II <br /> ARCHITECT/ ENGINEER INFORMATI N• <br /> Name: . /IL A % S 27 1 <br /> Phone (day): g5, - 9.'3G - 7gcl l <br /> Address: QLD /ylihncto uc S.) Scaife AC j City: l,.Ja y R ZIP: 5 S 3 9 1 <br /> Email and/or Fax: _ski a rck 97 Co qui l . C._671.._ <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑New Construction Single Family with ,I8Residence <br /> ddition attached garage Garage/Accessory Bldg. ,Public Sewer <br /> ❑Accessory Building 0 Single Family with 0 Deck <br /> ❑ Relocation detached garage ❑Office/Commercial 0 Private Sewer <br /> ❑Other: (specify) ❑ Multiple Family/Condo ❑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 Private Well <br /> Minnehaha Creek Watershed District(MCWD) 0 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) $ o5.5°y c)QC) <br /> Packet Last Updated: 04/1912013 <br /> Page 22 of 23 <br />