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1 � ' � A <br /> , . � t <br /> 1 ' <br /> STRUGTURE 1NFORMA'TION: <br /> .8truature Dlmenslana 1.Structure Dimenslons(coallnued� 2.Type af ConatrucUan , <br /> s,Lengih(it,)= Number oi badrooma� (]�o�d/Frnme <br /> b,Wtdth(ft.)� � Numbe�of gerepe staUs; �Maaonry . , ' . <br /> Araea in sauaca feei Aiteched� ❑Meta1 � � <br /> Q Pole Bldg. , � <br /> c.Basement� Deteched s • ❑ICF <br /> d,i``Story = �']On•aite Prefab <br /> e.2n°8tory� ❑Qtf»slte Prefab <br /> t� '�S Slory a ❑dthei(plea89 8pedfy): <br /> g,Tota)/kean ' , <br /> . ; <br /> REQUiRED SUBM1TTAt,S: � ! <br /> All of the Informaiion rnust be submitted in order for our a licatlon to be rocessed: ' . <br /> Nok <br /> ' Ertcloaed ' A iloable ' <br /> O C] Permit A Ilcafian <br /> � [7 Pro o ed Bulldin Plans <br /> O � MIV State Ene Cade Calculallone and e anEcal Code Re uiremenle Farm <br /> O 8urve m e sll utrements <br /> � O ❑ 3tormwater Poltuttan Praventlon Plan <br /> l7 liacdcov r Calculet on s • <br /> ❑. ❑ 3e Uc S etern SEte�vetluallo Re rt <br /> 0 0 AGcesa Petmit � <br /> CJ O Wefland Buffer Im rovemeM plan ; <br /> • O 0 � Ineered Plana for Retal in WelEa 4 fset pr above <br /> 0 Plan Review�ee <br /> ❑ � Cf Appttcetlan Escraw&Aereement <br /> 0 Other; <br /> APpUCANTlOWNER ACKN4Wl.EDG�MENT: � <br /> • Agrees to provtde all�nfotmation requlred or raqueated by fhe Bullding Department; <br /> • Agreee to pay the C[ry o!Orono tor angineering aoneul�ant revlew coste In excass of 5800; <br /> � Ceriii�ea thet the intonnetivn euppfled la trua end correct 10 tha beet ot hielher knowkedge. The eppltoent racagnizas that they <br /> � ara solely reeponsEbls tor submlttl� a camplete appHcation being aware that tspon faNure to do ao,the stafF hea no aitamallve <br /> but to rejeat It unkil It Is aamplete; <br /> � Ackrtawledgas Iho Eacrow Agreament Is compleled and sJgned; <br /> • Understands some or ell af iho intormallon that you are eskad io pravEde on this epplicatlon Is dassiQad by Slale law as elther <br /> private or canfide�ntlal. Pdveta deta is Iniocmatlo�whict�generally cannat be given to the publlc but can he given to the subJect <br /> af the deta. Confiden�al dats ia lniortnalton whEch generally cennot be glven b eiiher tha public or lhe subject oi the Qata. Aur <br /> purpose and tMended use of Utls intartt�ation 1s to annually update our recctde and r�carda of oiher govemmentaf agancias <br /> r9qWred by law. �f you re1'use 10 supply the InfarmaUun,the applicatfo+t may not he Issued. <br /> . Agravs tiiak in tha event that waather or other conditlons prevent the completian af an as-bullt survey at the tlme the <br /> Certtfiaate aF Occupanay la requested,a temporary Certlflcata oP Occupancy tr�ay be Isaued upon reaefpt of a 5�4,Op0 <br /> �scrvw ta eneure aompletion of fhe ae�butlt aurvey and a11 slte Improvemente. <br /> Appilcant'a Sfgnature: � � Dete, l2"�' �.�' "'" � � <br /> � Ownec's Signature: ' bate; Z ' Z� " �� <br />