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City of Orono <br /> Building Permit Application <br /> iSt)54 <br /> for New Structures or Additions 5.01 to <br /> Mailing Address: Per.nit number: , / l�`76 3 <br /> Q A�,T PO Box 66 <br /> W 1 VO Crystal Bay, MN 55323-0066 Date received: — �-7" <br /> Street Address:' Received by: <br /> 2750 Kelley Parkway <br /> 6� Plan review fee: t 1 .7 7,/p <br /> �` Orono, MN 55356 / <br /> `9'cEstio " Main: 952-249-4600 Total Fee: aof�-uo (oma/ <br /> 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 return . (Please print) <br /> GENERAL INFORMATION: <br /> Job Site Address: 17''10 0 1 / vee- n 1 1 1 1(,� <br /> Will this be a Parade of Homes, Remodelers Showcase Ho or other Display Home? ❑ Yes [5?).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: Rr,bi'r- 1- 4-rs five <br /> State License# Expiration Date: <br /> Phone: (cell) 9-51 yya,, 53 9 (office) SAME <br /> Mailing Address: 7003 (6 L?IS sfr ee+ 5 iiU City: W4vEf L y MN ZIP: 5-5-3 go <br /> Contact Person: go be,-'t Er S'tagi Applicant is: Contractor / omeo nw er- (Circle One) <br /> Email and/or Fax: E2 S T-AkD o GMA I L . (IpM <br /> PROPERTY OWNER INFORMATION: <br /> Name: IC o bpy' d- S+0I cy Er s-{-ii <br /> Phone (day): 951. -013 - oq 5v Mt') ,, <br /> Address: Sl 00_36 2 nrf S-Tt ek 5()) City: (�,41/L r:Z)' ZIP: 5 5?) 1,1() <br /> Email and/or Fax <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: OtoSoi 3c/ke.inh1e I KL Howie Desi9A <br /> Phone (day): G 1.2 Sly .2_ H g Q ( <br /> Address: "7� 7 lU fh S.f refit Scut City: Ptn`f1 xlo /Y)Af ZIP: 553/3 <br /> Email and/or Fax: 8RAAlowsC J- a LE @ Kc. kosinE8E s la f, (,pvY\ <br /> ARCHITECT/ ENGINEER INFORMATION: <br /> Name: <br /> Phone (day): <br /> Address: City: ZIP: <br /> Email and/or Fax: <br /> PROJECT INFORMATION: Description of project: <br /> 1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal& <br /> Water Supply <br /> New Construction laSingle Family with 0 Accessory Bldg./Garage <br /> Addition attached garage ❑ Deck X Public Sewer <br /> ❑Accessory Building 0 Single Family with 0 Office/Commercial <br /> ❑ Relocation detached garage N Residence 0 Septic <br /> 0 Other:(specify) 0 Multiple Family/Condo Retaining Wall(s) (Compliance certificate <br /> 0 Public 4-feet or greater may be required) <br /> **Any earth movement may require 0 Commercial 0 Storage <br /> MCWD review&permits. 0 Industrial 0 Warehouse 0 Public Water <br /> Minnehaha Creek Watershed District(MCWD) 0 Other: (specify) 0 Other(specify) <br /> 15320 Minnetonka Blvd;Minnetonka,MN 55345 Private Well <br /> Phone: 952-471-0590 / Fax: 952-471-0682 <br /> www.minnehahacreek.orq <br /> Estimated Construction Valuation (excluding land) $ 370 000 <br /> I <br /> Packet Last Updated: January 2016 <br /> Page 21 <br />