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Home My WebLink About2014-01287-VOIDED f �P City of Orono �, V�� Building Permit Application � ,�--� � for New Structures or Additions �N'��l Mailing Address: Permit number: �� "a� �� Q A TO PO Box 66 , / `w Crystal Bay, MN 55323-0066 Date received: � "7' � StreetAddress:' Received by: � ,� 2750 Kelley Parkway Plan review fee: F c,` Orono, MN 55356 t�kFSHO�� Main: 952-259-4600 Total Fee: 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. (P/ease print) GENERAL INFORMATION: j Job Site Address: � �� (;��1 � Will this be a Parade of Homes, Remodelers S case 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: State License# Expiration Date: Phone: (cell) (office) Mailing Address: City: ZIP: Contact Person: Applicant is: Contractor / Homeowner (Circle One) Email and/or Fax: PROPERTY OWNER INFORMATION: ,.�/� , � � � �Il , �Q/ S�. Name: /' I( � V� � Phone (day): � �� , /1 ,� Address: � ��b wG�C'C � Cit : ��„��1 �(1 ZIP: �j' �� Email and/or Fax 1'ti 1 fL � ' n � 1 N ' �'� �.�'1 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 ❑ Residence ❑Addition attached garage ❑ Garage/Accessory Bldg. �Public Sewer ❑Accessory Building f�Single Family with ❑ Deck ❑ Relocation � , ,� detached garage ❑ Office/Commercial ❑ Private Sewer ❑ Other: (specify) L U��^ �. ❑ Multiple Family/Condo ❑Warehouse /�ei;✓ �i� ❑ Public ❑ Storage ��Public Water ""Any earth movement may require ❑ Commercial ❑ Other(specify MCWD review 8�permits. ❑ Industrial L!`f�N � ❑ Private Well Minnehaha Creek Watershed District(MCWD) ❑ Other: (specify) ��;� 18202 Minnetonka Blvd Deephaven, MN 55391 Phone: 952-471-0590 Fax: 952-471-0682 www.minnehahacreek.or Estimated Construction Valuation (excluding land) � � / �O ' Packet Last Updated.� 04/19/2013 Page 22 of 23 STRUCTURE INFORMATION: 1. Structure Dimensions 1.Structure Dimensions (continued) 2. Type of Construction a. Length (ft.)= Number of bedrooms= ❑Wood/Frame b.Width(ft.)= Number of garage stalls: ❑ Masonry Areas in square feet Attached = ❑ Metal ❑ Pole Bldg. c. Basement= Detached = ❑ ICF d. 1S�Story = ❑ On-site Prefab nd ry_ e. 2 Sto — ❑ Off-site Prefab � f. '/z Story = �Other(piease specify): U.?��,�� /`15�'� g.Total Area= �c��,��✓ !� /1�� '�, —b" �IN�� ,� �rCl� REQUIRED SUBMITTALS: All of the information must be submitted in order for your application to be processed: Not Enclosed A plicable ❑ Permit A lication ❑ Pro osed Buildin Plans MN State Ener Code Calculations and Mechanical Code Re uirements Form Surve meetin all re uirements ❑ Stormwater Pollution Prevention Plan ❑ Hardcover Calculation s ❑ 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 ❑ Minnehaha Creek Watershed District Permit s ❑ ❑ Plan Review Fee ❑ ❑ Other: 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 governmental 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 ' requested, a temporary Certificate of Occupancy may be issued upon receipt of a $10,000 escrow to ensure co� le on o the as-built survey and all site improvements. ApplicanYs Signature: Date: l�-�D-/y Owner's Signature: , Date: Packet Last Updated: 04/19/2013 Page 23 of 23 � / ' DATA PRIVACY ADVISORY In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen warning", we wouid like to inform you that your request for a permit or license from the City of Orono or any of its departments may require you to furnish certain private or confidential information. You are notified that: 1. The information you furnish will be used to determine your qualification for the permit or license requested. 2. You may refuse to supply data, but refusal may require that the City deny the permit or license. 3. The information may be shared with other local, state or federal agencies to the extent necessary to process the permit or license. 4. If your requested permit or license requires Council action to approve, some information may become public. 5. You have certain rights under Minnesota State Statute 13.04 (see following page) to review private data on yourself. 6. Your full name is required to process this application or permit. � � � � � � ��, First Middle �, Last � � , f ' � , � V�� G Address � U�n� i,�`� � ��.�� I ��_`�� J� City State Zip Phone I understand , y�righ as s ted above. f�� , ._.._.,.. ; �_._. - Signature '` Packet Last Updated: 04/19/2013 Page 20 of 23 � s O � `� �� `J Q ��i � � � '�'c�v� � �' � � �� . �' � � �a � � � ca- � � � .� � � � �1 � '� � � - - - �_____� � --�.�_.:_:�-� - �-___--- �••— _ — __�. __._.__ ______._- -__ ________._.� �--�-- - , ____._--�-� l_______- � ____----�- _._.__________ � � _...__.---�_ � � _�-_="� � * �-�-.z � , � � __-------- Q' _____--- �,3 _ ..________.- �� --�—.- p - '� J � _'' ._._.___----'" � ��_�_--__..- ' �`�•� -�..-._._._ 0 � � � _�__ ._ o �..� .._„ _____....___.�.� i ----._........� x _._..__._ _ __ �� r� � � � . � � � � � � � �� ""' < � � t � Q-' d V , �'- . . � � � � = - � � �" � /-.`� � �1L • •►� � � � � � � � �k - -� :_:__... �� ` --_---- _� , _. .:_:_:_ -. ..___. , ._.__._.._ .. ..� ; -�-__=__ ��, ? :_.� �� `� — .._:e�� o ____.. --� � y '� �' / � � � � � _ . 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