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, c �, . � <br /> STRUCTURE INFORMATION: <br /> 1.8tructure Dimenslons 1.Structure Dimensicns(contlnwd) 2.Type of Construction <br /> e.Lenpth(fl.)= Number of bedrooma� �y��d!Frame <br /> b.Width(ft.)= Number of gerage steUs: ❑Masonry ' ; <br /> Areas in�are faet Atteched F ���8� � <br /> ❑Po1e Bldg. <br /> c.Basement= Detached= • ❑ICF <br /> � d.1a Story m <br /> O On•aite Pretab <br /> e.2n0 Sbry= ❑Oft slte Prefeb <br /> f. K Story = ❑Other(pleasa apecNy}: <br /> g.Total Arse� <br /> REQUIRED SUBMlTTALS: - � <br /> A11 of the information must be submitted in order for our a lication to be rocessed: : <br /> Not <br /> Enclosed ll�able <br /> 0 O Permit A Ikx�Hon � <br /> O 0 Pro osed BuNdin Plana <br /> O � MN Steto En Code Calculatbna and Mechanh�l Code R ulrements Form <br /> � � 8 maeitn all ulrements � <br /> C! � 3tormwater PolluUon Prevendon Plan <br /> 0 O Herdcover Cslculatbn s <br /> O O S S stem SNa EveluaUon Re rt <br /> Acc�s PemtR <br /> � O Wetland Buffer Im ment Plen <br /> O O lneared Plana for Retalnl WaAs 4 fset or above <br /> O O Plan Revlew Fee <br /> O Applicadan Eacrow 8�Agroement <br /> O O Other. <br /> APPUCANTlOWNER ACKNOWLEDGEMENT: � <br /> • Agrees to provide afl Information requlred or requeated by the Bullding Depa�tment; <br /> • Agrees to pay the Cfty cFOrono�or enpineering coneullant revl�r costs in axesss of$600; <br /> • Certiflea that the info�me�on supp9ed is true and cortect to the beat of hielher knowledge. The eppllceM reoopnizes that they <br /> are solely nespansible for submitting a camplete applicadon being aware that upon tallure to do ao,the ateff hee no altemativa <br /> but to reject it uMil it fs complete; <br /> • Ackrtowledges lha Escrow Agreement Is campleled and elOned; <br /> • Unde►stands aome or sll of the inlarmation that you are esked to provide an lhis applk�tion la dassl8ed by Siate lew as elther <br /> private or oonfideMfal. Pdvate dats is Infomnallon whlch generally cannot be ghren to lhe publ�but can be piven to Ihe subjed <br /> oi tha date. ConfldeMlal data is infarmalion whlch generally canoot be given to eNher the public or Ihe subjed of the�ta. Our <br /> pinpoae and t�rtended uae of this IntormeUon Is to annually updete our recaMs end records of other govemmentai agenc�ea <br /> required by law. N you refuse ta supply the InfonnaUon,the appUcation mey rsM be issued . <br /> . Agrees that(n the event�at wsathor or other conditions prevent the completion of an es-bWlt survey at ttre tima the <br /> Cerdficabs oi Oceupancy Is requesbed,e bmporsry Certlflcats of Occupancy msy ba Issued upon rocNpt of a 510,000 <br /> oscrow to ensure compladon ot tha as-bullt survey and a[I stte improvemente. <br /> Appllcant's Sig�alure; �� � � Date: �Z r 1 b '��? <br /> � Owner's Slgnature: ' Date: <br />