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1 �' <br /> , ' f .,� ' I ' � t <br /> STRUCTURE INFORAAATfON: � <br /> 1.Struaturo Dlme�lons 1.Stnicture Dlmansions(co�rtlnued) 2.Type of Construcflon , <br /> e,Length(ft.)= IVumber oi bedrooma� []yvood/Frame <br /> b.Width(ft.)= Number of gerape stalls: �Meaonry . ' , <br /> Araes In sauare feet Attached a ❑N�etel <br /> ❑Pole 91dg. <br /> c.Basemant� Oetad�ed= � �ICF <br /> d'�a story s ❑On•aite Prefab <br /> e.2n°3tory= ❑Of�site Prefab <br /> f. '�4 Story = ❑Other ease a e <br /> � P �� <br /> g.Total Area� ' , <br /> REQUIRED SUBMITfALS: • • <br /> Ap of the information must be subm�ted in order for your a lication to be rocessed: . <br /> Not <br /> Enclosed llcabla <br /> O 0 PermR A flc�tioa <br /> O 0 oged Buil�n Plane <br /> O 0 MN Stata En Code CalculaUons and Mechanicsd Code R uiremoMs Form <br /> O 3u me ell Wroments <br /> O O Stom�wate�Pdlution Prevemlon Plan <br /> O C7 H rdc�ver Calculation s <br /> O. O qc etem Stta Evaluatlan Re rt <br /> O � A�ceas PermR <br /> O 0 WeUsnd Bu(ter Im rovement Plen : <br /> � O � E Ineered Plana tor Retalnln Welle 4 feet or ebove <br /> � O Plan Review Fee <br /> � 0 Applkatlon Escrow&Agreem�t <br /> O fJ Oth�: <br /> APPUCANT/OWNER ACKNOWLEDGEMENT: ' <br /> • Agnees to provfde afl Iniormetio�requlred or requested by the BuiWing DepaNneM; <br /> • Agrees to pay the Clty of Orono for enginaering conaultant review costs in excess of SS00; <br /> • Ceriifies tF�at tha infortnatfon suppBed Is trua and wrrect to ihe best ot hislher kn�ledge. The eppllcaM reoopnizas that they <br /> are solely nesponsible tor aubmitdnp a complete applEcaHon bainp aware thst upon fellure to do so,the ateff has no akemative <br /> but to re)ect K uMil It ls complete; <br /> • Acknowledpas tha Escrow Ag�eamen!is completed end slgned; <br /> • Unde►stands some or all ai the infortnaHon that you are asked to provtde on Utis applicatlon is daoafflod by Slate law as eNher <br /> privete or oonfideMial. Private data Is infortnation which generally cannot be given to the publlc but can be glven to fhe subject <br /> of the dete. CoMldeMtal dste Is IntortnaUon whfch generaly canno!be give�to either the publlc or lhe subjed of the alata Our <br /> purpoas and tMendad uee oi thle UtormaUon Is to annually update our recorda and recards of other govemmontal agenc�s <br /> required by law. ii you refiise to aupply the informaUon,the applica�on may not be isaued. <br /> • Agrees that in the event that wsather or other condiUons prevent the compistlon of an as-bupt survey at the time tha <br /> CertMtcats of Occupancy Is requested�a temporary Certlflcate of Occupancy may be Issusd upon reaelpt of a 510,000 <br /> eacrow to ansure completion of the as•built survey and atl site Improvaments. <br /> ,�/ -- I � i <br /> ApplicanYs Signature: �"(_ � Date: �Z `�' � <br /> Owner's Signature: Date: <br />