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� �r p � � i ��n � O�t, b, LO '�� 2; 14, �N' Je � d Cmm� r� '� a f�o. �� ?. � ��TRUCTURE IN�ORMATION: ' 1.Structure pimenslons 1.Structure Dimensions(contlnued) 2.7ype oF Constructlon � a.l�ength(ft.)= Number of bedrooms=�__ Wpod�Frame b,Width(ft.)= � Number of garaye stalls: ❑Masonry Areas in square feet Atlached= ❑Metal � ❑P�le Bldg_ c. Basement- Detached- ❑ ICF d, 18`Story � ❑On-site PreFab e. 2id StOry= ❑Off-site Prefah f. '�Story = ❑4ther(please specify)� g.Total Area= _ __ REQUIRED SUBMITTA�S: All of the information must be submitted in order fior your a�plic�tion to be processed: � Not ' Enclosed A licable ❑ � Permlt A lication � ❑ ❑ Pro oSPd Bulldln Plans ❑ O MN State Ener Code Calc�dations and Mechanlcal Code Requirements Form ❑ d Sutve meefin all re uiremenls ❑ ❑ Stormwater Pollution Preventlon Plan ❑ ❑ hlardcover Calculation s I7 ❑ Se�tic System Site�valuatipn Report ❑ ❑ Access Permit . � p �V ❑ Wetland Buffer Im�rov�mant Plarl a ❑ En ineered Plans for F�etainin W811s 4 feet or above ❑ ❑ Mlnnehaha Creek Watershed(]istrlct Permit s ❑ ❑ Plan Review Fee � ❑ ` p Applicatlon Escrow&Ayreement ❑ � ❑ Other: APPLICANT/OWNER ACKNOWL�DGEMENT: • Agrees to provide all inforn�ation requlred or reyuested by the f3uilding Qepartment; . Agroes to pay the Gity of Orono for englneerinc�consultant review cost,s In excess of$500; . Gertifies Chat the informalion supplied is true and correcf to the best of his/her knowlecige. The applicant recognizes that they are solely responsible for submltling a complete application being aware that upon failure to do sv, the staFf has no alternative but to rejeGt ft untll It is comp(ete; • Acknowledges tYie Escrow Agreement is completed dnd Signecl; • Understands some or all of the informatlon that you are asked to provide on thls applicalion is classified by State law as either private or confidenpal, Prl�ate dafa is informatioh which generally cannot be given to the pubUc but can he given to thE subjeCt of the data. Confidential tlala Is Information which generally cannUt be glven to either the public or the SubJecl of the data. Our purpose and intended use of this informatlon Is to annuatly update our records and records of other govarnmental ayencles , reyuired by faw. If you refuse to supply the infonnation,the appllcaklon may not be issued. . Agrees that in the ev9nt th�t weaiher or other conditiorls prpv�nt the completlon of an as�built sUrvey at the tlme the CertifieatA af Oeeupancy is requested, a t�mporary Certlficate of Occupancy may be Issued upon receipt of a $10,D00 eserow to ensure completlon of the as-built survey and all slte Improvements. AppficanYs Signature: Date: � Owner's Signature: Date: