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lb-3 g n <br /> AA° <br /> City of Orono <br /> Building Application <br /> A lication <br /> for New Structures or Additions <br /> Mailing Address: Permit number: &CYO COQ/c3...1....y_O� PO Box 66 <br /> 0 Crystal Bay, MN 55323-0066 Date received: —�"/D <br /> Q��`" r- Received b I.e <br /> A `. "`�._:•, s. Street Address:' Y'_ , (�D IO " octal <br /> M,s,: <br /> 'A l' <br /> . j'i"�,N �� 2750 Kelley Parkway Plan review fee. 33�33 <br /> �kSHog� Orono, MN 55356 <br /> Total Fee: 553, <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us 7S.7 (o ,.5 <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: c- 0 0(CA I 1?' vrft- K. <br /> (a U4,. -- <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: > '.AI )),-"-Ci- (ja3.4- e,. "- C nIAA H iL <br /> State License# ao kI4 C.-4:3-1 Expiration Date: 3 — DO l 0 <br /> Phone: [psa - a1 A. ete,P D, (office) (cell) <br /> Mailing Address: i I&G(a e4v.A-"itco vA .r Ci�Y r�� ZIP: 5 S 3�'JI <br /> Contact Person: pw, Mato t A licant is: Co ra for Homeowner i <br /> Email and/or Fax: . pp (Circle One <br /> PROPERTY OWNER INFORMATION: <br /> Name: L► wa{r q- 3<� cD �l'SDV� <br /> Phone (day): <br /> 01 -?.- c{ 4 — -C.SS <br /> Address: y?il ©Jclnar,� !�w`k— �2A City: atDIA,0 ZIP: 45-c-354,0 <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 /> ❑ New Construction Single Family with Residence Water Supply <br /> Sin <br /> El Addition attached garage ❑ Garage/Accessory <br /> ❑ Accessory Building El Single Family with El Deck <br /> Bldg. El Public Sewer <br /> ❑ Relocation detached garage El Office/Commercial Private Sewer <br /> WOther: (specify) Zeis4AN4Ar ❑ Multiple Family/Condo ❑Warehouse <br /> w ❑ Public ❑ Storage ElPublic Water <br /> **Any earth movement may re uire ❑ Commercial ❑ Other(specify) <br /> MCWD review& permits. ❑ Industrial ❑ Private Well <br /> Minnehaha Creek Watershed District(MCWD) El 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) $ 2J5 <br /> Last Updated: 9/29/2009 <br /> - 17 - <br />