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HomeMy WebLinkAbout2011-00875-WITHDRAWN , � . City of Orono Building Permit Application for New Structures or Additions Mailing Address: /��0,j�. PO Box 66 Permit number: da/�— DD$75 �Q � Crystal Bay, MN 55323-0066 Date received: B`�� ' �� �I ��' '� I Received b : S 1�,a ^'�'�z� '` �,� Street Address:' y ��',�, �,. �`;`�,� �ti/ 2750 Kelley Parkway Plan review fee: �t���o� Orono, MN 55356 ___-' Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all required information must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: �. �D� �Tµ�'V�r , lU� Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes � No If yes,a special event permit is requrred with Police Department and City Councif approval 60 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking rs available. Non-permitted events will not be allowed. CONTRACTOR PPLICANT INFORMATIO . Name: <j'o H-IV �, L State License# iVo N�' Expiration Date: Phone: ��'- 7�3 `l �.,�j �. ! 1 3 0 (office) (cell) Mailing Address: po o ! 77 Cit : LoNG LAKc` ZIP: S S� Contact Person: �p f�-�/ /-F, L C /ti Applicant is: on ractor / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: Name: �"O f'1�O1� f'�"� �-C/ti Phone(day): _23 9 z 9 Z / / 3 O Address: �„78r0 6 7"�t Qt-b/E', ,V� City: �.aN6 �K� ZIP: 5-S"3 S"� Email and/or Fax ARCHITECT I ENGINEER INFORMATION: Name: Phone(day): Address: City: ZIP: Email and/or Fax: PROJECT INFORMATION: 1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8� Water Supply ❑ New Construction ❑ Single Family with ❑ Residence ❑Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer ❑Accessory Building ❑ Single Family with ❑ Deck ❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer ❑ Other: (specify) �� LO G�'T/ON ❑ Multiple Family/Condo ❑Warehouse ❑ Public ❑ Storage ❑ Public Water '"'Any earth movement may require ❑ Commercial ❑ Other(specify) MCWD review&permits. ❑ Industrial ��-2�� ❑ Private Well Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) �� 18202 Minnetonka Blvd r?d..._�� �--�� �t/�a 'Q �R��� �vQ�✓1: Deephaven, MN 55391 �� i"y-- Phone: 952-471-0590 �j/�}"/�,�� Fax: 952-471-0682 www.minnehahacreek.or Estimated Construction Valuation (excluding land) $ t�Q��` _� ���c,g-T� �j,9�Z� �rNn co NI/�7 r '�o G•�RA-G� ,�y iNsT,���r� 3 ���� 17Qaa75 l � �. - . . . � � � �,«�t ! # STRUCTURE IN ORMATION: 1. Structure.Dirpensfapns � 1. Structure Dimensions(continued) 2.Type of Construction ♦ f� � +� a. Length (ft.)= � Number of bedrooms= 6NL� �Wood/Frame � ❑ Masonry b.Width (ft.}= 3� Numberof garage stalls: 3 ❑ Metal Attached = lYaA4r' ❑ Pole Bidg. Areas in square feet �� 96 Detached =� ❑ ICF ❑ On-site Prefab c. Basement= Na Nt ❑ Off-site Prefab d. 1St Sto i z 9� � ❑ Other(please specify): rY = e.2"d Story= �.�z � f"dZ f,Z, /6 � f. '/2 Story = /VoNt' � g.Total Area= 1 �Z S `'r oz, S9 2 REQUIRED SUBMITTALS: All of the information must be submitted in order for your application to be processed: Not Enclosed Applicable � ❑ Permit Application ❑ @ Pro osed Buildin Plans ❑ 1�' MN State Ener Code Calculations and Mechanical Code Re uirements Form �d ❑ Surve meetin all re uirements ❑ �' Stormwater Potlution Prevention Plan ❑ '� Hardcover Calculation s I�..I(, -- R�LoG�I- /all/ ❑ �' Se tic S stem Site Evaluation Re ort ❑ � Access Permit ❑ � Wetland Buffer Im rovement Plan ❑ En ineered Plans for Retainin Walls 4 feet or above ❑ � Plan Review Fee ❑ ❑ Other APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all information required or requested by the Building Department; . Agrees to pay the City of Orono for engineering consultant review costs in excess of$500; • Certifies that the information suppfied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to reject it until it is complete; • Acknowledges the Escrow Agreement is completed and signed; • Understands some or all of the information that you are asked to provide on this application is classified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies required by law. If you refuse to supply the information,the application may not be issued. • Agrees that in the event that weather or other conditions prevent the completion of an as-built survey at the time the Certificate of Occupancy is requested, a temporary Certificate of Occupancy may be issued upon receipt of a $10,000 escrow agreement to ensure completion of the as-built survey and all site improvements. 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