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08/28/2012 07:04PM 9524407310 VICKITERCERO PAGE 02/05 <br /> STRUCTUR� INFORMATION: <br /> �.Structure Dimensions �.structure�imenslons(con�nued� 2 rype of Construcdon <br /> a_Len9��R)= � Number aF bedroo �'`�pd 1 Frame <br /> b.���)= _�_ Number aF garag stalis: I�l Masanry <br /> Areas in sauare(+ee# Atiached= ❑Metal <br /> []Pole Bldg- <br /> c.B�sem2ri� Delached= ❑IC:F <br /> d.1�Stary � ❑On-site Preiab <br /> e.2^d Story= C]Oif-site PreFab <br /> f. 34 Sbary = � ❑Other(ptease specify): <br /> g_Total Area= <br /> REQUIRED SUBMITTAIS: <br /> All of the informa#ion must be submittecl in order f�r our a lication to be processed: <br /> Nat <br /> Enclased A Eicable <br /> p ❑ Permit A Eicatian <br /> p ❑ Pro d Buildin Ptans <br /> p ❑ MN�Ener Code Ca�uladons and Meahanical Gode ui�nents Form <br /> ❑ � Surve meetin all re uirements <br /> ❑ � Storm�n�ter Pollution Prevention P�n <br /> � O Hardcovc�Calalation a <br /> p � Se 'c stem SiEe E�alu�tion R rt <br /> ❑ 0 Aoc�ss Permit <br /> p � 0 Wetland BufFer Im raverner►t Phan <br /> D En ineered Plans for Retainin Wails d faet or above <br /> p Q Minnehaha Creek WatersF�ed District Pecmi s <br /> p ❑ Plan Review Fee <br /> [a Q Applirntinn Fcrrc�r R AprP.P.mk+��tt' <br /> ❑ � Other: <br /> APPLICAN'�IOWNER ACF(NOWLEDC3EMENT: <br /> • Agrees Ea.provide all informatian r+equired or requested by the Building De�rtment; <br /> • Atitees to pay the Cipr af Drono for enflineennp consultant review costs En excess nf S50fl; <br /> � CerU�ias tt�at the ir�forrr�tion�rpphed is true and correct to the best aF hisJher knawledge. The appl'�ant recognizes that`they <br /> are sol�ly responsible for submitting a oomplete application being aware that upnn failure to do so,the si�ff has no albemative <br /> but to reject it urRil it is completia; <br /> . a,clmo�nec+ges the Escrow Agreerrberrt is corr�plet�a ar,a si9nad; <br /> . Understands sort�or alI of the inFormation that you are asked to pravide an this application is olassified by SCate faw as either <br /> privotc ar oonTiderrtinl. pri+rato d�m is ininrmqtien which gcncrally c�nnat kic 9ivcn bo thc public but can bo givon bo thc subjcot <br /> oP the daia. Cvnfldential d�d.is ini+ormation which generally Ce�nnot be given to either the pubfic or the subject of the data. Our <br /> purpose and intended use oF th�s iniormafion is t6 annually upda09 our records and records of a�er govemrr�ntal agencies <br /> required by laar. If you refuse b supply#he infiormation,t.�e apptication rr�y not be issued_ <br /> . . . .... . . . .... . ..... ......... . <br /> . . <br /> _ ': ,-�.�s�: .� ,�'ttl�e.t1..,.�ttVe <br /> .. .. .. . ... .... .. <br /> ;. <br /> !44��7t�;tli��:.that�W�lfier'�.o��:cond"Rions:= fr�Ve�1t-ttie�:cQmpletlor of'an:ai�b�1�. .. ... m� <br /> • e�crdw�,ta:�+st�re:com'.ietton ofth.e,:as buit� ' , p.. �� � . <br /> �pit�f?e�;�'Or�wpan�►:��requssted;.�:t��t�.ry, Ce�ti�caC�= . � ceuP�ncy:m�!Y:Ire:issu�_�upo:n,:rec�pt:of':a�►O;�qq <br /> .. .......� _ .. p_.... .. . sur.yey,and.atl:sit�;inipftivemet�s: <br /> �� ,•�,r �� � �/ <br /> ApplicanYs,Sigrmtt�rc: � l�P , _ `�'�V� C7V�G' Datc: ,�., (�l �a fl�� 3 <br /> Owner's Signature: __ ��: <br />