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City of Orono <br /> 1 <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address: <br /> Permit number: <br /> Po Box 66 <br /> 20 — / l <br /> Crystal Bay, MN 55323-0066 Date received: /2i(4 /�C., <br /> Street Address:' <br /> `1, ��I°0 eceived 4y: E ' <br /> 2750 Kelley Parkw y 2� Plan review fee: <br /> to <br /> �` Orono, MN 55356 CIG Cf _ <br /> t"�k stto�`� Main: 952-249-4600 if.) <br /> tal : <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 /> ION: ix, D Q t1 4 rr) 01 Omen <br /> Job Site Address: tri d <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 ivilPtre <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APP (CANT I FORMATION: <br /> Name: 1 • )A _• <br /> State License# C ,. Expiration Date: - <br /> Phone: cell — "a — eireVAIMAJW _ - . — <br /> Mailing Address: . S I /= ! ZIP: 3 R <br /> Contact Person: - air 4 Applicant is: ontrac or / Homeowner (Circle One) <br /> Email and/or Fax: j pe;,,1en i /_e+-itoh he,evvc ,C o <br /> -441 <br /> PROPERTY OWNERFORM TION: i/ <br /> Name: p#1,,., i4 uii't.4r" <br /> Phone(day): 2_ c, 4 _g 6 FS <br /> Address: g /f/1%/�, vi L/.1e'!P City:C�C�'/Sjb� ZIP. --)J/ <br /> Email and/or Fax p rn Li /46-4-A, 17 JA /.- - G yi <br /> ARCHITECT/ENGIN§ER I FORMATION: <br /> Name: II e4.5-4,,-7 <br /> Phone (day): 7 6 7/ 7 <br /> Address: 9 / 60 2-71o( cam/ /�G City: /4;/P ZIP:5-3.—Vry <br /> Email and/or Fax: <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 <br /> attached garage ❑Accessory Bldg./Garage <br /> ["Addition 0 Deck <br /> ❑Accessory Building 0 Single Family with Office/Commercial ❑ Public Sewer <br /> ❑ Relocation detached garage Residence ,Private Sewer <br /> ❑ Other: (specify) ❑ Multiple Family/Condo "'❑❑❑ Retaining Wall(s) <br /> 0 Public 4-feet or greater 0 Public Water <br /> **Any earth movement may require 0 Commercial 0 Storage <br /> MCWD review&permits. 0 Industrial 0 Warehouse XPrivate Well <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd <br /> Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> www.minnehahacreek.org <br /> Estimated Construction Valuation (excluding land) $ c 50000 co <br /> Packet Last Updated: August 2015 <br />