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tsji,........" 1 ft--"� <br /> City of Orono b1 ��" <br /> Building Permit Application 5C1 1 <br /> '1 r 1 2 ji(' <br /> for New Structures or Additions r1 <br /> Mailing Address: Permit number: Gwlg-&)082--1 <br /> "V.-0A,,,, Box 66 <br /> VQ Crystal Bay, MN 55323-0066 Date received: /-oZ V-/ <br /> Street Address:' Received by: ‘1///(-V <br /> -y, ,� 2750 Kelley Parkway Plan review fee: at/g-ODI a3 <br /> �` Orono, MN 55356 <br /> ��1x�stio�`� Main: 952-249 4600 T tM�,Ft/1-000 3 55-3J' <br /> Fax: 952-249-4616 www.ci.orono.mn.us �i-J f)'X/ / Ofl ,d�J 1� <br /> This application form must be completed in full and all required information must be submitted._ o <br /> Incomplete applications will be returned. (Please print) �oY/J`��� y <br /> GENERAL INFORMATION: <br /> Job Site Address: i 1 q 5 C-c6717..0-reT CIR_O t-1 q e M *.J 55141 <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/APQ-.I-ICANT IN ORMATION: <br /> Name: -' 7:c.k DON G0.l4'4k(— iYY, <br /> State License# '1 ' . 1 c). Expiratio Date: .3/4 f iq <br /> Phone: (cell) Up,- VOL- (et (office) (t)-- X 76 -11)u <br /> Mailing Address: �(k.S "el" f L. N City: Lc fC.cfct/1 ZIP: 5 ;. j <br /> Contact Person: yiji- -00,A Applicant is: Contractor / Homeowner (circle One) <br /> Email and/or Fax: IN- Iftsi ,L,;11 <br /> PROPERTY OWNER INFORMATION: <br /> Name: TWIN\akS k1AMt t..7164". <br /> Phone (day): 60-f-30t-S(07$ <br /> Address: Li 1t "` +��4 S '�` %RAS City: MtaN4,11Po,.IS ZIP: , 54iiS <br /> Email and/or Fax �-}-e,NA , h,o„AA. WON__®... "C-1/4" « (..10FC.TM - <br /> ARCHITECT/ENGINgER INFORMATION: :, <br /> Name: `C-t1 01 NQ►� 4 s Nwti, <br /> Phone(day): 6 51 - 3C) - 4,3 5 <br /> Address: City: ZIP: <br /> Email and/or Fax: Tt1t1DVat-;crt4 V tY1aC., 6,nk li i A <br /> PROJECT INFORMATION: Description of project: <br /> 1.Type of Project 2. Proposed Use 3.Structure Type 4.Sewage Disposal& <br /> Water Supply <br /> A,New Construction A Single Family with Cr]Accessory Bldg./Garage <br /> ❑Addition attached garage ❑ Deck ❑Public Sewer <br /> ❑Accessory Building ❑ Single Family with ❑Office/Commercial <br /> ❑Relocation detached garage x Residence yi Private Sewer <br /> ❑Other:(specify) ____ ________ ❑ Multiple Family/Condo DI Retaining Wall(s) <br /> ❑ Public 4-feet or greater El Public Water <br /> **Any earth movement may require ❑ Commercial ❑Storage <br /> MCWD review&permits. ❑ Industrial ❑Warehouse iXPrivate Well <br /> Mlnnehaha 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.orq <br /> Estimated Construction Valuation (excluding land) $ U,50f O(Do. 00 RECEIVED <br /> Packet Last Updated: August 2015 JAN 7 j U l u <br /> Page 21 <br /> CITY OF ORONO <br />