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<br /> � KtVtIV�U
<br /> City of Orono
<br /> Building Permit Application JU� � 82016
<br /> for New Structures or Additions C�OFORONO
<br /> Mailing Address: Permit number: �U�(Q-UtJ 7 ,�
<br /> QA, PO Box 66
<br /> � f v0 Crystal Bay, MN 55323-0066 Date received: 7-�f -� (O
<br /> Street Address:' � � ��, ec ved by:
<br /> � ,�- 2750 Kelley Parkway ��"r�^�" ;
<br /> y�' c,` Orono, MN 55356 .�yL lan review fee: .
<br /> t"�xEsr►o4�' Main: 952-249-4600 Total Fee: �l� ���
<br /> Fax: 952-249-4616 wt��v��.ci.orono mr�.us
<br /> This application form must be completed in full and all required information must be submitte / 4�D` �
<br /> Incomplete applications will be returned. (Please print) 6 U
<br /> GENERAL INFORMATION:
<br /> Job Site Address: �-,��(��C`� ���'���,,���.��
<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 approva!60 days prior to the event. Shutt/e bus service will be
<br /> required unless applicant demonstrates suHicient on-site parking is available. Non-permitted events will not be allowed.
<br /> CONTRACTOR/APPLICANT II�FORMATION:
<br /> Name: ti�r.-�.�,4- ���5������l � � A�./
<br /> State License# `�iC �� t �r� Expiration Date: 3 �, ' �'�
<br /> Phone: (cell) �� �-Za o�-{•�-� (office) (f„� ����-}— �,-.�K
<br /> Mailing Address: _� S',.� � ' Ci : ,�� ZIP: �5 yn(
<br /> Contact Person: �M� �'Y�� E.1�,t�--�� Applicant is: Contractor / Homeowner (Circle One)
<br /> Email and/or Fax: 'k ,n.�G��,��,,,�, mc��.�-Lc��, . ��;�,,.�
<br /> v �
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: � � � �,.2 ,q�,Th�.t _ -{-
<br /> Phone (day): �'S 2 - Z'u --�i��—
<br /> Address: �� G .���� �,,a� City:� r-,n 3�, ZIP:5��� �
<br /> Email and/or Fax ���_,_. �,�� �,y��,,.����.�.�L,N„� ��
<br /> ARCHITECT/ ENGINEER INFORM qTION:
<br /> Name: �,;:�., al 1S�
<br /> Phone (day): �,�z —�-�� — , �
<br /> Address: ; �- �' � �,..�:, �\ Cit : !� ,p ZIP��/Z�_
<br /> Email and/or Fax: Y�e�c��cJ `�2`�� C�r�n.cfl.�o �t �
<br /> PROJECT INFORMATION: Description of project:
<br /> 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8�
<br /> Water Supply
<br /> ❑ New Construction �Single Family with ❑Accessory Bldg./Garage
<br /> �--Addition attached garage ❑ Deck ,�Public Sewer
<br /> ❑Accessory Building ❑ Single Family with ❑ Office/Commercial
<br /> ❑ Relocation detached garage �Residence ❑ Private Sewer
<br /> ❑ Other:(specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s)
<br /> ❑ Public 4-feet or greater �Public Water
<br /> **Any earth movement may require ❑ Commercial ❑ Storage
<br /> MCWD review 8� permits. ❑ Industrial ❑Warehouse
<br /> ❑ Private Well
<br /> Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify) ❑ Other(speCify)
<br /> 15320 Minnetonka Blvd
<br /> Minnetonka, MN 55345
<br /> Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> www.minnehahacreek.or
<br /> �
<br /> Estimated Construction Valuation (excluding land) $ � vc� , �, �DO
<br /> Packet Last Updated: August 2015
<br /> Page 21
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