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City of Orono <br /> Building Permit Application <br /> ►•��, r for New Structures or Additions <br /> O�O� MailiPO Boxr66 Permit number: o?40/ -Q� <br /> Crystal Bay, MN 55323-0066 Date received: 9jl q�j <br /> Street Address: Received by: <br /> 0472750 Kelley Parkway Plan review fee: <br /> .44tr Hoe* Orono, MN 55356 <br /> Total Fee. /37, /3 <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: i S Lo S oeolJo Qa.lk5 D(C. <br /> Will this be a Parade of Hbmes, Remodelers Showcase Home or other Display Home? ❑ Yes El No <br /> If yes,a special event permit is req fired 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: Se(ect Edpr'lreeet, CoriStchi <br /> State License# S 47' &O Expiration Date: 3 - 3\ - 1 3 <br /> Phone: £10 ( , a q-0-79 (office) Ln 5 i Za9 3130 (cell) <br /> Mailing Address: 1Zon Ceti Ce Po1)t Cu r yr zacCity: • l'.CUJ r+-,N ZIP: SS tam <br /> Contact Person: "3-4,..-vs-. t Ck.e r Applicant is: ontracto7)/ Homeowner (circle one) <br /> Email and/or Fax: _)o,So•.1fJsizler}cvcr7rceN <br /> PROPERTY OWNEcFOR ATION: <br /> Name: ol `j 1/x c <br /> Phone(day): q 403-.20 s <br /> Address: (S t„S oro/ie, e3e=k5 D2 City: ZIP: 5 S 3 SLP <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 II� <br /> 1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ❑ New Construction 0 Single Family with ® Residence <br /> ❑Addition attached garage 0 Garage/Accessory Bldg. 0 Public Sewer <br /> ❑Accessory Building ® Single Family with 0 Deck <br /> ❑ Relocation r detached garage 0 Office/Commercial 0 Private Sewer <br /> I Other:(specify) V- , ❑Multiple Family/Condo ❑Warehouse <br /> ❑ Public 0 Storage ❑ Public Water <br /> *"Any earth movement may require 0 Commercial 0 Other(specify) <br /> MCWD review&permits. 0 Industrial 0 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.m i n nehah acreek.o rq <br /> Estimated Construction Valuation (excluding land) $ c?fer.8 3EtM, <br /> Last Updated: 4/26/2011 <br /> - 19- <br />