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STRUCTURE INFORMATION: 1. Structure Dimensions 1.Structure Dimensions(continued) 2.Type of Construction a. Length(ft.)= �N�/ � �� Number of bedrooms=� �'Wood/Frame ii b.Width(ft.)= � � � Number of garage stalls: ❑ Masonry Areas in square feet Attached = � ❑ Metal c. Basement= /.�J�� Detached = ❑ Pole Bldg. 3 ❑ icF d. 1 S`Story = / 3L �� ❑ On-site Prefab e. 2nd Story= ❑Off-site Prefab f. 'h Story = ❑Other(please specify): g.Total Area= �� REQUIRED SUBMITTALS: All of the information must be submitted in order for your application to be processed: Not Enclos d Applicable ❑ Permit A lication ❑ Pro osed Buildin Plans ❑ MN State Ener Code Calculations and Mechanical Code Re uirements Form ❑ Surve meetin all re uirements ❑ Stormwater Pollution Prevention Plan ❑ Hardcover Calculation s Q ��R—t/13�J -$-- ❑ Se tic S stem Site Evaluation Re ort -�— ❑ Access Permit --8-- ❑ Wetland Buffer Improvement Plan -$— ❑ Engineered Plans for Retainin Walls 4 feet or above ❑ ❑ Plan Review Fee ❑ ❑ Other: APPLICANT/OWNER 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 mtended 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. � � ' p , � ,� � �' ApplicanYs Signature: �� ° � Date: ��t�(/�`,Z�� E Owner's Signature: Date: Packet Last Updated: 03-06-2012 -22 -