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-�—�' - —--. .._..—_. .. .. <br /> ._... __._.,_...; ._ :.... � ; <br /> � . � � ' <br /> , ; <br /> i <br /> • i <br /> . ! <br /> :STRUC7URE INFORMATION: � �' <br /> '�.Structur�a Dbnenskns 9.8tructure Dlmenslons(contlnusd) 2 Typa of Constructlon <br /> a.Lengtlt(ft.)= Number of bedrooms=� I <br /> ��Wood/Frame <br /> b.Width(1kj= Number of perape s#alls: ❑Masonry <br /> � ❑Metal ', <br /> Areas irr sauere ie� Attached=� ; <br /> ❑Po�e Bldg, <br /> a Besement� f 3 93•S DtkBChed a Q i <br /> d.9'�3tory = �393••�'� �ICF j <br /> ❑On-si6e Prsfab ' <br /> e.2nd Story= � � ❑OfFaile Profab ! <br /> f. 34 Story = ����p�� ! <br /> g.Total Aree= 2, i��� �): i <br /> , I <br /> I <br /> REQUIRED 8UBMITTALS: � <br /> All of the iMormation must be submitted tn order for our lication to be ocessed: � <br /> Not <br /> � En k icable <br /> � Pemtft ication � <br /> C] P aed Buildl Plans -� <br /> CI 'r. MN State Code Calculatlons and Mechenioel Code R uireme�s Form <br /> Ll Su meeli all ulremerds ; <br /> 0 ' .. � Stidrtn Polludon Preverrtion Plany ti,. <br /> � ' Ha�dcover Cak�latia�s <br /> � t�n 9it�Eeaaldatlo a.. � <br /> , <br /> o �.. <br /> � ro�Pl�rre-ferAet�ini �+k�f�erorabovs � <br /> 0 Minnehaha Creek Wabeished Dietrlct Permit s <br /> � � Pbu�` eY�ew Fee � <br /> O Application Es�r&AgreemeM ' <br /> 17 O Other. <br /> APPLICANT/OYVNER ACKN�WLED(3EMENT: <br /> • Agrees to provide alt infirtnatlon roquired or requesled by the Bu�ldnp Department; <br /> • Agreaa to pay the CIly ot Orono for w�gineseing oonsultant revlaw costs in e�ocps M�500; <br /> • CerUfles U�at the Informetbn supplled is true and oarect to ihe best ot Ma/her knowledge. The applicant recogniaes that they <br /> are soley reeponsfble for e�mftting a complete applicatlon being aw�+e that upon falluro to do so,the staff hae no slbematMs <br /> but b reJeat ft urn�it ia oomplebe; ' <br /> • A�ov�Aedgee the Escrow Agreemerrt is campieted end sipned; <br /> • Undaistands some or al!of the fMormadon that you are�to provide an thls applbatlon is dasaiffed by Stabe Iaw es eitha' <br /> private or oonflder�ial. Pmra6a dete la IMermation which peneraNy cannot be giNen to fhe pudic but can 6a given to the subject <br /> of�e da�. Confldentlal data is inf�rmatbn whbh generelly aannot be gtven to elther fhe publia or ihe aubject of ihe date. Our <br /> putpose and Intended uea of this iniormadon le to annually updete our reca+da and reoorda M other governmer�tal agenaes <br /> required by law. If you refuse bo aupply the infom�atlat,the application may not be iesued. <br /> • Aqnss that tn thv ownt that wosthar or other condltlons prevent the oomp[etlon of�n as-built survey pt ths tima the <br /> Cw#Nlcabe of O�upancy Is requested,a ternpaary Certtflc�ata M OccupaAcy may be issued upon�ipt of a�a0,000 <br /> sscrorr to e�ure completlon of the as-buiK wrv�y and dl siba Improwmenb. i <br /> ,�plicarrt'e SiBnature: � Date: 9�.��ZE9/.� <br /> owners signature: oate: 9��.7�/3 � <br /> . , <br /> i <br /> ( <br /> � <br /> f <br />