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<br /> City of Qrono
<br /> Building Permit Application
<br /> far New Structures or Additions
<br /> MailingAddress: .�C� fC� -�(,�"%'S
<br /> �0,� PO Box 66 Permit number: C��
<br /> � Q Crystal Bay, MN 55323-0066 , Date received: � vv �/d
<br /> a � a StreetAddress:' Received by: �' ZG 10--
<br /> �'.E, � � '� �,ti�' 2750 Kelley Parkway ���i�'� Plan review fee: � l�I �5y C�CC�t�,�
<br /> r9xESIiO�'� Orono, MN 55356 ��
<br /> Total Fee;f�� `
<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�Z 1 6����-3 'P�-���� vl � �r,l� I��Q� 1�(A
<br /> Job Site Address: !
<br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes ❑ No
<br /> If yes,a specia/event permit is required w8h Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
<br /> required un/ess applicant demonstrates sufficient on-site parking is availab/e. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: �}-e:�� fi �p�.(r�.�r•, 1�.-C,
<br /> State License# "�'1 Z\ �' Expiration Date: ''j-3E.Za�a
<br /> Phone: 5'Z. �-'13- S�-3S o�ce C��."Z 4i�--S1Z$ (cell)
<br /> Maifing Address: �Q���o W'��r...g �. a . Cit : �� � ZIP: 5 S39
<br /> G�ntart Person��,�„Q 5 .{� ,. �„��1,.p�- o„�Applicant is� Contractor / Homeowner ICircle One1
<br /> Email and/or Fax: �,,.�;,,._,,.{�,,�.o,- � s-�--.�;.,.p,- �dnn�.i,r.,L,., �c+� / (g'Sz,� �-l3-52.oi�
<br /> PROPERTY OWNER INFORMATION: f
<br /> Name: !�a� S�-�t,i�
<br /> Phone(day): � -a�4 -
<br /> Address: Z ,,��,.xb Cit : �rop-o ZIP: S3S�
<br /> Email and/or Fax rn•�a.,,,,,p (o�� 0 za1 . c,r�w•
<br /> ARCHITECT/ENGIN ER INFORMATION:
<br /> Name: J;a 1� r�c�
<br /> Phone(day): � 41 - S 3�
<br /> Address: 16�34o hn: �� � �.�c� Cit :h-�' ��-� ZIP: S'Sj9)
<br /> Email and/or Fax: y,;e w� S .e;..p ► wv.,�, � �o r-. '3�- ?_p�
<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) $ �CX� p� ...—
<br /> Last Updated: 9/29/2009 '
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