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City of Orono Li,g <br /> Building pp Permit Application <br /> for New Structures or Additions / <br /> Mailing Address: Permit number: 027/7`— 9 9 <br /> 0,�\ PO Box 66 <br /> Q Crystal Bay, MN 55323-0066 Date received: / 7r� <br /> I Received b <br /> 1I <br /> 41:11)6s <br /> Street Address:' Y' <br /> 2750 Kelley Parkway Plan review fee:2Orono, MN 55356 <br /> = Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us crCul vt.(rd <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: atiiiiiiiiikoMPICZ o O tiZo J U `l L-� KG tJ <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: NIH Homes <br /> State License# BC419931 Expiration Date: 3-31-15 <br /> Phone: 763-753-1750 (office) 612-221-1853 (cell) <br /> Mailing Address: 6840 213th Ave City: Elk River ZIP: 55330 <br /> Contact Person: Colt Applicant is: Contractor / Homeowner (Circle One) <br /> Email and/or Fax: colt@nihhomes.com Fax-763-753-8582 <br /> PROPERTY OWNER INFORMATION: <br /> Name: NIH Homes <br /> Phone(day): <br /> Address: City: ZIP: <br /> Email and/or Fax <br /> ARCHITECT/ENGINEER INFORMATION: <br /> Name: Alexander Design <br /> Phone(day): 952-473-8777 <br /> Address: 401 East Lake Street City: Wayzata ZIP: 55391 <br /> Email and/or Fax: <br /> PROJECT INFORMATION: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> ['New Construction ✓❑Single Family with ❑✓ Residence <br /> ❑Addition attached garage Garage/Accessory Bldg. E] Public Sewer <br /> El Accessory Building Single Family with ✓ eck <br /> ❑ Relocation detached garage Office/Commercial ❑ Private Sewer <br /> ❑ Other:(specify) 0 Multiple Family/Condo 0 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) $ 500,000 <br />