HomeMy WebLinkAboutVOIDED - 2016-00904 , ,
.
� City of Orono
Building Permit Application
for New Structures or Additions
Mailing Address: Permit number: ����p—�� Q
� �Q PO Box 66
Q Crystal Bay, MN 55323-0066 Date received: D�()�' �
StreetAddress:' f�� Received by: �
y ,�- 2750 Kelley Parkway '�I Plan review fee:
F c.� Orono, MN 55356 V
l�kESHO�� Main: 952-249-4600 Total Fee:
Fax: 952-249-4616 v��a�w.cLoror7c 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: I
Job Site Address: �� 9 D ��.o� �Oa
Will this be a Parade of Homes, Remodelers Showcas Home or other Display Home? ❑ Yes ❑ No
If yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be
required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
CONTRACTOR/APPLICANT INFORMATION: �, ,
Name: Cc��.�� tv���---`� ���ti�i-�-..<.c:;z ���,-� �L.c._
State License# �j� �,�y�-7p��C� Expiration Date:
Phone: (cell) �lZ--(v l�-� -�-! c��7� (office) 5t�m E
Mailing Address: 1 YI�W ���-5 �:�-2c_L-�- Cit : La�Ct v.� ZIP: � �r�4�1-
Contact Person: -;i�y�,i.�-t-� Applicant is: ontractor_� / Homeowner (Circle One)
Email and/or Fax: �i,�c���.;�,., — �L�cL;,� rz,r',�,��-
PROPERTY OWNER INFORMATION:
Name: e� �ct-�.-� r'�- ���T�c=�r=
Phone (daY)� �nf�g Zl 3 - `F�'Z�
Address: �4 5� � c��xQ _ � Cit : ��,vc� ZIP:
Email and/or Fax n,tc� o� �jl�.E �c c ,C�, ,
ARCHITECT/ ENGINEER INFORMATION:
Name:
Phone (day):
Address: City: ZIP:
Email and/or Fax:
PROJECT INFORMATION: Description of project:
1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal 8�
Water Supply
❑ New Construction ❑ Single Family with ❑9ccessory Bldg./Garage �
❑Addition attached garage ��Deck Public Sewer
❑ Accessory Building ❑ Single Family with ❑ Office/Commercial
�Relocation - �aG�tc t��'�L'.'`��'1 detached garage ❑ Residence ❑ Private Sewer
❑ Other:(specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s)
❑ Public 4-feet or greater ❑ Public Water
**Any earth movement may require ❑ Commercial ❑ Storage
MCWD review&permits. ❑ Industrial ❑Warehouse ❑ Private Well
Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Other(speCify)
15320 Minnetonka Blvd
Minnetonka, MN 55345
Phone: 952-471-0590
Fax: 952-471-0682
www.minnehahacreek.or
Estimated Construction Valuation (excluding land) � � ��
� All(� n 1 �n�
Packet Last Updated: August 2015 CITY OF ORONO
Page 21
STRUCTUFtE INFORM/�TIOtJ: , �
1. Structure Dimensions 1. Structure Dimensions(continued) 2. Type of Construction •
a. Length(ft.)= 1 l I i � Number of bedrooms=
[rWood/Frame
b.Width(ft.)= Z� � Number of garage stalls: ❑ Masonry
Areas in sQuare feet Attached= ❑ Metal
❑ Pole Bidg.
c. Basement= Detached = ❑ ICF
d. 15t Story = ❑ On-site Prefab
e. 2"d Story=
❑ Off-site Prefab
f. '/2 Story =
❑ Other(please specify):
g.Total Area=
REQUIRED SUBMITTALS:
All of the information must be submitted in order for your application to be processed:
Not
Enclosed A licable
❑ D Buildin Permit Escrow A reement and Fees
❑ ❑ Plan Review Fee
❑ O Com leted A lication Form
❑ ❑ Pro osed Buildin Plans—2 full size sets,to scale and 1 reduced 11 x 17 or 8'/z x 11 set
❑ ❑ Minnesota State Ener Code Calculations and Mechanical Code Re uirements
❑ ❑ Surve —2 full size,to scale meetin ALL surve requirements
❑ ❑ Hardcover Calculations
❑ ❑ Se tic S stem Certification
❑ ❑ Minnehaha Creek Watershed District(MCWD)Permit or
Documentation from MCWD statin no ermit is re uired
❑ ❑ Landsca e Walls and/or Retainin Wall Plans
❑ ❑ Stormwater Pollution Prevention Plan SWPPP
❑ ❑ Access Permit
� ❑ Data Privac Adviso Form
APPLICANT/OWNER 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 supplied 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 lemporary Certificate of Occupancy may be issued upon receipt of a $10,000
escrow to ensure completion of the as-built survey and all site improvements.
ApplicanYs Signature: / /(r � Date: _ C-� - � � E1/�"
� �
Owner's Signature: Date: n + � �G� �
Packet Last Updated: August 2015
Page 22
PLAN REVIEW CHECKLIST FOR NEW STRUCTURES / ADDITIONS
Address: � � Permit No.: l�1�� - WK�T
Description of work: l�V�— l � �' Date Rec'd: O' �' �(�
i( CIOCQ
Septic review by: ✓liW'(/I� � ��Tv1' Date Approved: '—�
Zoning review by: Date Approved:
Building review by:_ ��Q� ��'�� Date Approved: 0 ' '' ��
Grading review by: N H"� ,�,_,�,� Date Approved: "�'—"—"''
Zoning District: � � Zoning File#: Reso#: Reso Date:
Zoning: Lot Area: SF/AC Width: Lot Coverage: SF %
Survey Submitted: � Yes 0 No Date of Survey: Revised date(?):
Landscape plan submitted? � Yes � No Landscaper:
Proposed Setbacks:
F nt (Lake) R r(Street) ( N S E WD ( N S E Wl� Other Buildings Wetland
Side Side
Defined Height: Peak Height: FFE: FFE minus 6 feet= (Existing Contour;
Perimeter(linear feet) = 50% = L.F. below grade
Basement? � Yes 0 No, Stories
FOR A BUILDING WITH A BASEMENT OR CRAWL SPACE: FOR A BUILDING ON A SLAB FOUNDATION:
The distance between the lowest proposed Slab at or above grade—
START WITH floor(of the basement or crawl space)and measure from hiqhest existin�c
the highest point of the roof. START WITH ra ade to the highest point of the
roof even if fill was brought in to
If you have a... elevate home.
SUBTRACTION • GABLE OR HIPPED ROOF(no Slab below grade—measure
(BASED ON windows): Subtract half the distance from highest existing grade to the
ROOF TYPE) between the highest point of the roof hi hest oint of the roof.
to the low point of the corresponding If you have a...
gable or hipped roof SUBTRACTION ' GABLE OR HIPPED ROOF
• GABLE OR HIPPED ROOF(with (BASED ON (no windows): Subtract half
windows): Subtract half the distance ROOF TYPE) the distance between the
between the top of the highest highest point of the roof to
window and the highest point of the the low point of the
roof corresponding gable or
hipped roof
• ALL OTHER ROOF TYPES(flat, . GABLE OR HIPPED ROOF
mansard,etc):No subtraction. (with windows): Subtract
SUBTRACTION Subtract the distance between the half the distance between
(BASED ON basemenUcrawl space floor and the the top of the highest
EXISTING highest existing grade adjacent to the window and the highest
GRADES) foundation OR 10 feet(whichever is less). point of the roof
• ALL OTHER ROOF TYPES
(flat,mansard,etc):No
EQUALS Defined building height subtraction.
Defined building height
EQUALS
Updated: May 2016
z:\forms\plan review checklist 5-2016.docx
Average Lakeshore Setback
Shoreland District MCWD Permit Met? Bluff
� Yes p No Permit Number: � Yes � No 0 N/A � Ye No �
0 N/A—see attached Setback:
Stormwater Quality Existing Proposed
Overlay District Tier Hardcover Hardcover Variance Required CUP Required
circle one % and sf % and sf
� Yes � No � Yes � No
1 2 3 4 5 Type(s): Type(s):
Fees to be Char ed YES NO
Permit �/
Plan Review �,/
State Surcharge �/
Investigation Fee �/
SAC—Number of SAC Units �
Other(specify)
Square Foota e $ per Square Foota e
Basement X = $
1 St Floor X = $
2nd Floo� X = $
Garage X = $
Estimated Construction Value: $ �nd�
Orono Inspections Required Work Requiring Separate Permits
�Footing � Site 0 Plumbing 0 Grading/Filling
� Poured Wall � Silt Fence/Erosion Control � Mechanical � Fire
� Foundation Survey � Hardcover Removal � Fireplace � Water Connection
� Framing 0 Other(specify) 0 Masonry 0 Sewer Connection
❑ Waterproofing/Drain tile � Mfg. 0 Lawn Irrigation
O Foundation Waterproofing � Other(specify) 0 Landscaping
Framing
� Insulation
0 As-Built Survey
inal
� Lathe Required State Permits
� Other(specify)
� Well 0 Electrical
REMARKS (in-house):
OFFICIAL REMARKS-TO BE NOTED ON PERMIT AND INITIALLED:
0 See Builder Acknowledgement Form
� Prior to release of escrow money an as-built survey and hardcover calculations must be submitted and approved.
Updated: May 2016
z:\forms\plan review checklist 5-2016.docx
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