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DEC 13,2013 18:19 7634276789 Paq�. .'. <br /> , � <br /> STRUC'FURE lNF4RMA710N: ' <br /> 4.SUvcturs Dimensians 1.Struatur�Dimen�ions(contlnued} , 2.�ype of Gonetnictlon -�...-T------ -- --� <br /> / J <br /> ' a.Length(R.)Q l`� 3 ' Numher af bedrooms=�,_ <br /> . �Wood 1 Frame <br /> ; b.Width {ft.)- �`� Number of garage stalls: �Mesonry <br /> lAr�9s in sauare f�t � Atfached=� � ❑Me19t ' <br /> i ' <br /> 1 I <br /> j ❑Pole Bldg. � <br /> c. Basement= �R� ( Retached= ( �j ICF �, <br /> 1 e. 151 sto►y = �Y� <br /> � !� � ❑On-Siie Prefab <br /> I g '1"d,�p�_ ( � <br /> ' �]Off-Site Pre�b <br /> i t %Story = `{� I ❑Other{piease specify?: ,. __ �' <br /> � g.Total Ares= � � I' <br /> j � - -� --�---- ------- � ..._.r......�.. _ �.- --- __ � <br /> REQUfRED SUBMITTAt,S: � <br /> A{I of the information must be subrrtitted in order for your application to be processed:_ _ ________' <br /> j—��-------- - Not ..._.._..r....�__ � <br /> � Enciosed �W A ilcable�__ ' <br /> ��.-~_�� .. Perm d A }_pp iCatian _........_ ..._._._._....____......._—..�j_.._.—.. �',,' <br /> j � -�. � ry�ProposedBufldin ('lar►s _ _ ...,. -- a <br /> ��—�� __ _ Q _ ' MN State Energ�Code CafCufetion6 end MechaniCs!_Code Requirements Fbrm ___�_ j. <br /> a Surv mettin alt re uirements T � `�..._.� y.��,,, -- . _ 1 <br /> ❑ ❑ Stormwet6rPollution F�revention Plsn " ,___ ___.__ ..,____. _�__� <br /> ,__...,_ ____.... � _-.--- Hardcavef CsIculBfion(�._ _. _. -----� <br /> . _ _�— ,,.... <br /> G� ❑ 5apiic bystem Site�vaivat�on Re,pat . _. ,_. � <br /> .� . ---- .u�------ Rccess Permit �_..__._._.._.._ ---- -------� <br /> C3 ❑ WetEend Buffer Im ovemeM Plan ,,,,�,.,__._ _.. .M_.___—____._..a <br /> 7 � En ineer8�Plane for Retainin Wa�ls 4 feet or above' <br /> -------- -._ ..._....... __, ,. <br /> CJ _ ❑ Plan Revigw�ee i <br /> I_.._. ❑ _--- t--- CI _ C)ther: .. _..... _.�— _ _. ..._ .�..- ---------- <br /> APpLICAN�'lOWNER ACKNOWI.EpO�M�NT: <br /> �. - - �------�-- . . ...._. _...�._�.� <br /> i . Agrees to provide afl informat�on required or requested by She Building D¢�artment; � <br /> � • Agrees to pay the City ot Orono tor engi:�aring consul�rt review co!ffi in exCese o1 SS40; �I' <br /> • Certifies thaf ihe iniurmatfon supplied is true enc� correct to U�e best of hislher knc�Medge. Th� appllcant tecognizes that they �' <br /> � are sofely responsible for submitting 8 Gorslp(ete applfcatio� being aw�re that upon i8ilute to do so, the stefF has no aflemat�ve �, <br /> but to re�ect lt untsl it is complete; , <br /> ' . Acknowledpes the Escmw Aflreemen!fs completed t�nd signed; � <br /> j I <br /> • Uc�clerstaryds some or�Jl ot ihe information thai you are asked ta provide on fhis appticatwn rs ciassified by Slate i8w as Bi;iter ; <br /> private ar con�iden4ial. private data is information which generaEty cannot be given io the publsG but Can ise given to;h8 subNsd '� <br /> � of the data. Cvnfidentlal date is fnformation whlch ger►erd;ly Cennot bC given to either the putih�c or the subject of the �81a Gu; <br /> purpose and intended i�se of thfs iniorm�tion is tn annually updete our records and records of otrier governmemai agenves <br /> required Dy Eaw. If yau refuse to supplY tt►e informetion. the sppiication may not be issued. � <br /> . Agreee tt'i�t in the ev�nt tl�pt wenther or other Condltlons prevent the camptetlan of an as-butft survey at tha Eirne thc j, <br /> Cvrtific�ye of Occupancy is requ4ataQ, a temporary Certfficab of OCcupancy may i�a Issueci upon nacetpt of a Sf0,000 ' <br /> i escrow to ensure completlon of the as-buflt survey snd al!alte Improvements_ <br /> '.._.�..------ - ------�-- �--.....,.._.. _.______� _ , �,......_._._._....�,.._._ ---- --� <br /> Appficant's Signat�re: �� Uate_ _„ _f��i 2 ____ <br /> Owners Signature: _,_,� J ' Date: c�. .,_.._ <br /> *�acicet last upastea: O�a6-20�2 <br /> _�� _ <br /> i <br /> I <br /> f <br />