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01/01,/2011 12:11PM 9524407310 VICKITERCERO PAGE 02105 STRUCTURE INFORMATION: 1.Structure Dimensions 1.Structure Dimensions(continued) 2.Type of Construction a. Length(ft.)= Number of bedrooms= Wood/Frame Masonry b.Width(ft)= 10 Number of garage stalls: ❑Metal Attached= ❑Pole Bldg. Areas in sough feet Detached= ❑ICF ❑On-site Prefab a Basement= ❑O"its Prefab d. 1e Story = �,Y ❑Other(please specify): e.2"°Story= f. %Story = g.Total Area= REQUIRED SUBMITTALS: All of the information must be submitted in order for your application to beprocessed: Not Enclosed Applicable ❑ ❑ Permit Application 0 0 ProposeProposeO Building Plans ❑ D MN State Ener y Code Calculations and Mechanical Code Requirements Form D D Survey meets allrequirements) D ❑ Stonnwater Pollution Prevention Plan O ❑ Hardcover Calculation(s) O ❑ Septic S stem Site Evaluation Report a 13 Access Permit 13 O Wetland Buffer Improvement Plan O O En ineered Plans for Retainin Walls 4 feet or above O D Plan Review Fee ❑ 0 Other APPLICANT ACKNOWLEDGEMENT; Agrees to provide all information required or requested by the Building Department; Agrees to pay the City of Orono for engineering consultant review costs in excess of$500; • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Acknowledges the Escrow Agreement is completed and signed; • Understands some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other governmental agencies required by law. If you refuse to supply the information,the application may not be issued. • Agrees that in the event that weather or other conditions prevent the completion of an as-built survey at the time the Certificate of Occupancy Is requested,a temporary Certificate of Occupancy may be issued upon receipt of a$10,000 escrow to ensure completion of the as-built survey and all site improvements. Applicant's Signature: Date: Lest Updsted: 4J=011 -20-