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City of Orono <br /> Building Permit Application <br /> for New Structures or Additions <br /> Mailing Address. 3_od/OQ <br /> o,, PO Box 66 <br /> Permit number: / <br /> 0 Q Crystal Bay, MN 55323-0066 Date received: 47—/p2"13 <br /> A ' e A. Street Address:' <br /> Received by: �7 <br /> ��� ��A):t � �t' 2750 Kelley Parkway Plan review fee: ci d 6/ $9 <br /> \kestio'� Orono, MN 55356 ak) 3 _'OO�9 <br /> Total Fee: v, <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: “,S O,rrive-,L&,-k I jtct- <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes Z 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: S J /I- i . cLia Sync,- ci (3u; (4cr-.r <br /> State License# Expiration Date: 3/3///3 <br /> Phone: 7G,3 ^ q79- S5-5-5- (office) (,l 2- 2,09- Sq/6 (cell) <br /> Mailing Address: 5')5/ Ma'n Sf; t eox 3/PZ Cit :/Y(„pp((a;,, ZIP: SS3.,7 <br /> Contact Person: (,,r,,�/ ,'rn kin son Applicant is: ontrabtor / Homeowner (circle One) <br /> Email and/or Fax: Jo tin 5,,,,it� wausatyhame,s _cy n.1 <br /> PROPERTY OWNER INFORMATION: <br /> Name: 8i1( °f' Mollie- IQ 1, rtvaS <br /> Phone(day): (,1 2 - 9 y0- 57 `/7 <br /> Address: 3(,30 L;vIreys++on Ave, City:way?-a,--rt ZIP: .S5-3? I <br /> Email and/or Fax Mollie-wr 8- i ma;(. cowl <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: Wcu.s,iA l-fowl&S " Suyt.crrc Qu; (1.4„(1-- <br /> Phone(day): 703- 4 7f- SETS" <br /> Address: 6-icol ,fgarn 0_ t3ok 38z. City:frL /Z 04ik ZIP: .SSS357 <br /> Email and/or Fax: ;t,y,,SanJ ®, l../a.SRul7orHes.car►, <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ErNew Construction ®Single Family with in Residence <br /> ❑Addition attached garage ❑Garage/Accessory Bldg. 0 Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑ Deck <br /> ❑ Relocation detached garage ❑Office/Commercial 0 Private Sewer <br /> • ❑Other: (specify) ❑Multiple Family/Condo ❑Warehouse <br /> 0 Public 0 Storage ❑ Public Water <br /> **Any earth movement may require 0 Commercial ❑Other(specify) <br /> MCWD review&permits. 0 Industrial [Sr 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) $ 1/S Z 000 <br /> Packet Last Updated: 03-06-2012 <br /> ,o1 <br />