|
� � g q��. �s
<br /> ,
<br /> � >
<br /> -� �� \0 City of Orono
<br /> � Building Permit Application
<br /> far New Structures or Add�tions
<br /> Mailing Address -.��`, i i' - �`�?:f;' �
<br /> �0,�. PO Box 66 Permit number:
<br /> 0 ,\ Q\ Crystal Bay, MN 55323-0066 � Date received: � o�/ �/�
<br /> ��� ��� . � Received by_ � � "�C; 1�—
<br /> ,� �,j�'�.T��_:y ,,i Street Address: _
<br /> '�',�, ,�.�,���y�,9_ ti�' 2750 Kelley Parkway ���` ����� � Plan review fee: ' � -=�;/ 4���� ��•��3
<br /> ty '��� 1�y`���' Orono, MN 55356 �� �`" "
<br /> xEsxoi'' '
<br /> Total Fee:���� �
<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: � ' `�c�� �� � L� , r �,,,',,.,1�,,,���o� �
<br /> Job Site Address: ' � Z (3 �-e�.,.3� - U T�.1 �VI' I
<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. Shutt/e bus service will be
<br /> required unless applicant demonstrafes suffrcient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: `�'�-;�� �- k��r^-�^, �.-"-�,
<br /> State License# �l Z1 �'—� Expiration Date: 2j-3i�Z�i c
<br /> Phone: � 5z� �"l� - S�-3S (office) C��Y, 4�4--S1Z�- (cell)
<br /> MailingAddress: �'?����o r��....e � �c . Cit : � � � ZIP: SS'�`11
<br /> C�ntar.t Person•�„�,�„e S .{;.,.t;.y � (�`� y��1,.Q,rya.v Annlicant is� Contractor / Homeowner �c�.�ie o�e�
<br /> Email and/or Fax: zc11,�-;,.�-� �{�-.�-4�� e� 4-S--e:.-�,- le��r�z(�►..�. �c+� � �Q�2,� �-13—52�`u
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: 1� a.� 5�..-�s-�
<br /> Phone (day): Z. 1 -G't'Z 6r
<br /> Address: Z� ,� �x� � Cit : f�r�� ZIP: `jS`���
<br /> Email and/or Fax r�n' �.. 4,i'Z 0 :zo1 . �w�
<br /> ARCHITECT/ ENGINEER INFORMATION:
<br /> Name: J�c� I�a. ��*^
<br /> Phone (day): �Z, 4-1' - S 3�
<br /> Address: (B34o hn� kh�.}-a,., a �.�c� Cit :`�-�� ��a z►P: SS 3 9 �
<br /> Email and/or Fax: :1,,�e � C�7 S -e�'..p� -e1 w..��n � �or�-� `� '�-- 20�
<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. �Public Sewer
<br /> ❑Accessory Building ❑ Single Family with ❑ Deck
<br /> ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer
<br /> ❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse
<br /> ❑ Public ❑ Storage ❑ Public Water
<br /> "'Any earth movement may require ❑ Commercial ❑ Other(specify)
<br /> MCWD review& permits. ❑ Industrial �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.or
<br /> Estimated Construction Valuation (excluding land) $ � �C.� C�C� --
<br /> Last Updated: 9/29/2009
<br /> - 17 -
<br />
|