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AUG 26,2009 10:22A 9529929289 page 2 <br /> STRUCYURE INFORMATION: <br /> 1.Structuro Dlmenalons 1.Structure Dlmenelone(contlnu�d) 2.Type of Co�atruction <br /> a.Length(f1.)= -� Number of bedrooms= �j Wood/Frame <br /> ❑Masonry <br /> b.Width(R,r �1 Number of garage stalis: ❑Metal <br /> Attached= ❑Pole 81dg. <br /> Areas in souare feet Detached= ❑ICF <br /> ❑On-site PreFab <br /> c.Basement= []Off-si�e P�efab <br /> d, 1°1 Story = ❑Other(please speciiy): , <br /> e.2nd Story= <br /> f. '/a Story = <br /> g,Total Area= ��`t U <br /> RE�UIRED SUBMITTALS: <br /> All of the information must be submitted in order for our a lication to be processed: <br /> Not <br /> Enclosed A IlcaDle <br /> ❑ Permit A lication <br /> ❑ Pro osed Buildin Plans <br /> ❑ O MN State Ene Code Calculations and Mechanical Code Re uirements Form <br /> fd- ❑ Surve meelin all re uireme�ts <br /> 0 ❑ Stormwate�Pollution Prevention Plen <br /> ❑ O Hardcover Calculation s <br /> ❑ ❑ Se lic S stem Site Evaluation Re ort <br /> 0 ❑ Access Pe�mit { <br /> p r p Wetland Buffer Im rovement PIe� �� <br /> � ❑ En ineered Plans for Retainin Walls 4 Fee�or above <br /> ❑ O Plan Review Fee <br /> ❑ O Other <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information reQuired or requested by the Building Departmenr, <br /> . Agreea to pay the Clty ot Oro�o tor enginee�ing coneultant review costs in excesa nf S600; <br /> • Ce�tiFes that the information supplied is Irue end correCt�o�he best o(his/her k�owledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being ewere that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete, <br /> • Acknowledges the Escrow Agreement is completed end signed; <br /> • Some or all of the information that you aPe asked to provide on this appllca0on is classified by State law as either priva[e or <br /> oonfidential. Private data is information which generally r,anno�be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally Cannot be giVen lo eithe�the public or the subject of the dala. Our purpose and <br /> intended use of thi6 informa�ion is So dnnuelly updete our records and records of other governmental agencies required by law. <br /> If you refuse to supply Ne infortnatlon,the application may not be issued. <br /> � � r�"a <br /> qppiicent'e Signeture� ��`� �-���—QXZ� Date: C�� Z� ���7 <br /> Lsal Updaled: 6/22/2008 <br /> -2�- <br />