HomeMy WebLinkAbout2014-01034 - detached garage CITY OF ORONO * 2014 - 01034 *
2750 KELLEY PARKWAY DATE ISSUED: 10/13/2014
ORONO, MN 55356-
952 249-4600 FAX: 952 249-4616
ADDRESS 2380 WATERTOWN RD
PIN 34-118-23-33-0004
LEGAL DESC UNPLATTED 34 118 23
LOT 000 BLOCK 000
PERMIT TYPE ACCESSORY STRUCTURE
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE GARAGE-DETACHED
ACTIVITY 438-ADDNS OF RES GARAGES&CARPORTS
VALUATION $ 28,000.00
NOTE: SEPARATE PERMITS REQUIRED:ELECTRICAL(STATE)
DETACHED GARAGE
*NOTE: PRIOR TO RELEASE OF ESCROW FUNDS AN AS-BUILT SURVEY MUST BE SUBMITTED AND APPROVED. INITIAL:
—3
APPLICANT PERMIT FEE SCHEDULE 445.25
MINNEAPOLIS GARAGE BUILDERS LLC
STATE SURCHARGE(VALUATION) 14.00
TOTAL 459.25
4520 SHADY BEACH CIRCLE Payment(s)
MINNEAPOLIS, MN 55359- CREDIT CARD 9443 459.25
OWNER
MARTIN,WILLIAM&PATRICIA
2380 WATERTOWN RD
LONG LAKE,MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be performed according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within days of the date of issuance,or if construction is
suspended fora ri of 180 days at any time after work has commenced.
The applic re on i le for assuring all required inspections are
requested' con cc with the State Building Code.This permit may be
revoke t any or d use
/C'i
Applicant Pe ee Sign to Date -issued- y Signature Date
CITY OF ORONO
BUILDING PERMIT APPLICATION 5c1.
FOR NEW STRUCTURES OR ADDITIONS
�0 Mailing Address: Permit number: Zo
PO Box 66
Crystal Bay, MN 55323-006611 D Date received: Fit zz Ig
Street Address:' Received by:
�F 2750 Kelley Parkway Plan review fee: Z g,7 ,
q
Orono, MN 55356
��kESH°��` Total Fee:
Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us a- )C_ 0AIM10,1t,t A 'KC
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: J ,00 wGt-tGYtOtc�e1 LOh �K� COror, o J
Will this be a Parade of Homes, Remodelers Showcase 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
Name: 7bpeyll , M t n ri e_a 00 6
lls - V-Age_ �Vd ere,
State License# `fp Expiration Date:
Phone: (cell) (i�- office
Mailing Address: S c C. 'rc - Cit P l_s . A/ ZIP: 5 5 3 5
Contact Person: Joe v Applicant is: / Homeowner (circle One)
Email and/or Fax: /fit C CO►'11
ROPERTY OWN R INFORMATION;
Name: G r�l( G� Q fl
Phone (day): a-1I-Z 3 - `10 10
Address: 13 iso VJ e 0Wh City:Lcmq LGA-ke_ ZIP:
Email and/or Fax __b_f-M ar tl•n OR a�0 V�hna , CO rN
ARCHITECT/ ENGINEER INFORMATION:
Name:
Phone (day):
Address: City: ZIP:
Email and/or Fax: n
PROJECT INFORMATION: Description of project: V ��tac_.�64 e'ctracl e,
1. Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal &
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) ❑ Multiple Family/Condo ❑Warehouse
❑ Public ❑ Storage ❑ Public Water
""Any earth movement may also require ❑ Commercial ❑ Other(specify)
MCWD review&permits. ❑ Industrial ❑ 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) $ C)0O
i
f
STRUCTURE INFORMATION:
1. Structure Dimensions 1. Structure Dimensions (continued) 2. Type of Construction
a. Length (ft.)= _ Number of bedrooms = tWood/Frame
b.Width (ft.)= Number of garage stalls: ❑ Masonry
Areas in square feet Attached = ❑ Metal
❑ Pole Bldg.
c. Basement= Detached ❑ ICF
d. 1 st Story = ❑ On-site Prefab
e. 2nd Story= ❑ Off-site Prefab
f. '/z 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 Applicable
29 ❑ Permit Appiication
❑ ❑ Proposed Building Plans
❑ ❑ MN State Energy Code Calculations and Mechanical Code Requirements Form
A ❑ Survey(meeting all requirements)
❑ ❑ Stormwater Pollution Prevention Plan
❑ ❑ Hardcover Calculation(s)
❑ ❑ Septic System Site Evaluation Report
❑ ❑ Access Permit
❑ ❑ Wetland Buffer Improvement Plan
❑ ❑ Engineered Plans for Retaining Walls 4 feet or above
❑ ❑ Plan Review Fee
❑ ❑ Application Escrow&Agreement
❑ ❑ 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 is requested, a temporary 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.
Applicant's Signature: Date: 1 2-0+
Date:
Owner's Signature: i' - i�
PLAN REVIEW
�CHECKLIST FOR NEW STRUCTURES / ADDITIONS
Address/Permit Number: !—✓o6 v\
Description of work: (,Z2,%2-+
Septic review by: Date Approved:
Zoning review by: Date Approved:
Building review by: slik Date Approved: 10- 10 - / Ly
Grading review by: Date Approved:
Zoning District: KV 1.6 Zoning File#: Reso#: Reso Date:
Zoning: Lot Area:. �Q f S q' 14-AC Width: Lot Coverage: S F+
Survey Submitted: �Zr es O No Date of Survey: ' � Revised date(?):
Proposed Setbacks:
Front( e), Rear(S et) ( N S d-" W ) ( N S E W ) Other Buildings Wetland
1 Si a !D Side �O
q ti io' Z0 NJ
Defined Height: Pear' "-' is 6 feet= (Existing Contour)
Perimeter(linear feet)_ _Ok? 0 YES
FOR A BUILDING WITH A BASEMENT OR C
The distano i k SLAB FOUNDATION:
START WITH proposed flc
space)and t rRH The distance between the top of slab and
If you have a the highest point of the roof.
GABLE If you have a...
• GABLE OR HIPPED ROOF(no
window i windows): Su half the distance
distanct between th est point of the roof
of the rd to the point of the corresponding
SUBTRACTION correspc 'ION or hipped roof
(BASED ON ROOF GA I BLE OR HIPPED ROOF(with
TYPE) dovencs; _) windows): Subtract half the distance
distae', between the top of the highest
highest w window and the highest point of the
point of th roof
• ALL OTHE ALL OTHER ROOF TYPES(flat,
mansard,i mansard,etc):No subtraction.
(TION Add the distance between the top of slab
ATION Subtract the dist BASED ON and the highest existing grade adjacent to
N EXISTING basement1crawl 6Ndc:e noor and the EXISTING the foundation.
highest existing grade adjacent to the GRADES
foundation OR 10 feet(whichever is less). EQUALS Defined building height
EQUALS Defined building height
Shoreland District MCWD Permit Received Average Lakeshore Setback Met? Bluff
0 Yes 0 No .0 N/A 0 Yes AINO
0 Yes AINO'o _ 0 Yes 0 No )eN/A
Permit Number: ; ; Setback:
Stormwater Quality Existing Proposed Variance Required CUP Required
Overlay District Tier Hardcover Hardcover
0 Yes No 0 Yes No
Type(s): Type(s):
Updated: January 2013
v:\forms\plan review checklist 2013.docx
REMARKS (in-house):
Fees to be Charged YES NO
•Permit1Aa`
Plan Review
Investigation Fee
77 . k
Other(specify)
Square Footage $per Square Footage
Basement X = $
lot Floor X = $
2nd Floor X = $
Garage X = $
Estimated Construction Value: $ Z `b;Q6o
Orono Inspections Required Work Requiring Separate Permits Required State Permits
0 Site 0 Plumbing 0 Grading/Filling 0 Well
0 Hardcover Removal 0 Mechanical 0 Fire Electrical
eZ Footing 0 Septic 0 Water Connection
0 Poured Wall 0 Fireplace 0 Sewer Connection
0 Foundation Survey 0 Masonry 0 Lawn Irrigation
0 Radon Rock Bed 0 Mfg.
19 Framing 0 Other(specify)
0 Insulation
'AAs-Built Survey
Final
0 Wetland Buffer
0 Other(specify)
REMARKS (in-house):
Other Review: Reviewed by: Date Approved:
Access: Existing: 0 YES 0 NO New: 0 YES 0 NO
OF ICIAL REMARKS -TO BE NOTED ON PERMIT AND INITIALLED
Yi 61/' 'b .r�.��- l j ' J �u (a o (6 -ICU i 4 SU r,v�w l .
Updated: January 2013
v:\forms\plan review checklist 2013.docx
Christine Mattson
From: Thomas Dietrich [TDietrich@minnehahacreek.org]
Sent: Monday, October 13, 2014 8:23 AM
To: Christine Mattson; Melanie Curtis
Cc: Trish Martin
Subject: 2380 Watertown Rd, Orono- MCWD No Permit Needed
Good morning Christine & Melanie,
After review, the proposed project located at 2380 Watertown Rd, will not require a permit from the District. If you
have any questions or concerns, please feel free to contact me.
Thanks,
Tom Dietrich
District Representative
Minnehaha Creek Watershed District
15320 Minnetonka Boulevard
Minnetonka, MN 55345
Direct: (952) 641-4518
Main Office: (952)471-0590
Fax: 952-471-0682
www.minnehahacreek.org
10
MINNEHANA CREEK
WAYMNED DISTRICT
1
Christine Mattson
From: Lora Pohtilla [Ipohtilla@minnehahacreek.org]
Sent: Friday, October 10, 2014 8:45 AM
To: Christine Mattson
Subject: RE: 2380 Watertown Road
Hello Christine,
Yes,Tom spoke to Trish earlier this week and we have reviewed her survey and determined that she will not be needing
a permit from the MCWD.
If you have any questions please feel free to contact me
Thank you,
Lo ra
From: Christine Mattson [mailto:CMattson@ci.orono.mn.us]
Sent:Thursday, October 09, 2014 10:03 AM
To: Permitting
Subject: 2380 Watertown Road
The property owner,Trish Martin, at 2380 Watertown Road said she talked to someone at the MCWD who said she
didn't need a permit from you. Can you please send me an email to that affect?
Thanks!
Christine Mattson
Planning Assistant
City of Orono
2750 Kelley Parkway Orono MN 55356 (physical address)
PO Box 66 Crystal Bay MN 55323-0066 (mailing address)
W952.249.4620 A952.249.4616
M cmattson@ci.orono.mn.us -ff� www.ci.orono.mn.us
Office Hours: Monday- Friday 8 am to 4:30 pm
OUR OFFICE WILL BE CLOSED: Tuesday, November 11, 2014
1
Christine Mattson
From: Christine Mattson
Sent: Tuesday, October 07, 2014 10:25 AM
To: 'Trish Martin'
Cc: 'Kelly- Schoborg Land Services, Inc.'
Subject: RE: 2380 Watertown Road /#2014-01034
Good Morning Trish,
I see we have received your escrow money and agreement,thank you. I received the updated survey from Kelly this
morning. Please contact the Minnehaha Creek Watershed District at 952-471-0590 to determine if your project triggers
any of their permitting requirements.
Christine
From: Trish Martin [mailto:btmartin09O8(cOyahoo.com]
Sent: Tuesday, October 07, 2014 8:31 AM
To: Christine Mattson
Subject: Re: 2380 Watertown Road / #2014-01034
Hi Christine,
We paid the required escrow amount on Sept.12.
The request for a silt fence to be shown on the survey has probably been sent to you by now.
Is there something we are supposed to do with the watershed district?
Thanks,Trish Martin
Sent from my iPad
On Oct 6, 2014, at 11:36 AM, Christine Mattson <CMattson@ci.orono.mn.us>wrote:
William & Patricia,
Attached is a copy of the letter and enclosures being mailed today. Please don't hesitate to
contact me if you have any questions.
Christine Mattson
Planning Assistant
City of Orono
2750 Kelley Parkway Orono MN 55356(physical address)
PO Box 66 Crystal Bay MN 55323-0066 (mailing address)
9 952.249.4620 g 952.249.4616
M cmattson@ci.orono.mn.us -i� www.ci.orono.mn.us
Office Hours: Monday- Friday 8 am to 4:30 pm
OUR OFFICE WILL BE CLOSED: Tuesday, November 11, 2014
<letter.pdfs
i
Christine Mattson
From: Christine Mattson
Sent: Monday, October 06, 2014 11:37 AM
To: btmartin0908@yahoo.com
Cc: 'Kelly- Schoborg Land Services, Inc.'; Lyle Oman
Subject: 2380 Watertown Road/#2014-01034
Attachments: letter.pdf; eng comments.pdf; Escrow Agreement- Building Permit w Erosion Control
2014-01034.pdf; Survey Requirements- March 2014.pdf
William & Patricia,
Attached is a copy of the letter and enclosures being mailed today. Please don't hesitate to contact me if you
have any questions.
Christine Mattson
Planning Assistant
City of Orono
2750 Kelley Parkway Orono MN 55356 (physical address)
PO Box 66 Crystal Bay MN 55323-0066 (mailing address)
W 952.249.4620 8 952.249.4616
cmattson@ci.orono.mn.us -lt� www.ci.orono.mn.us
Office Hours: Monday- Friday 8 am to 4:30 pm
OUR OFFICE WILL BE CLOSED: Tuesday, November 11, 2014
1
1'O` rO
CITY OF ORONO
' Street Address: I Mailing Address: Telephone(952)249-4600
2750 Kelley Parkway P.O.Box 66 Fax (952)249-4616
19 c�
Fsxo� Orono,MN 55356 Crystal Bay,MN 55323 www.d.orono.mn.us
k
October 6, 2014
William&Patricia Martin
2380 Watertown Road
Long Lake, MN 55356
Re: Building Permit Application#2014-01034
On September 12, 2014 the City received a building permit application for a detached garage. Your application is
incomplete. The following items must be submitted or revised in order for your application to be considered
complete and for the plan review to continue:
1. Certificate of Survey. Surveys were submitted; however our engineer has the following comments. See copy
of enclosed email. Please provide two copies of an updated,full size certificate of survey which meets all of
the City's survey standards (enclosed).
2. Escrow & Escrow Agreement. Permits involving grading and/or review by the City's engineer require
submittal of an escrow and an escrow agreement. The purpose of the escrow is to guarantee reimbursement
to the City for out-of-pocket costs incurred during the review of your plans. Additionally this escrow will
guarantee conformance with City Code Chapter 79 relating to erosion control and stormwater. The required
escrow amount for this project is$2,500. The escrow agreement is enclosed. The property owner must sign
the escrow agreement and submit a check for$2,500.
Your project may trigger the Minnehaha Creek Watershed District's (MCWD) permitting requirements; please contact
the MCWD directly at 952-471-0590 regarding your project. Please note, the City of Orono will not issue a building
permit without a copy of MCWD permits or documentation from the MCWD stating the proposed project does not
trigger any of their permitting requirements. The above information is required in order for the plan review to
continue. Please feel free to contact me at 952.249.4620 or by email at cmattson@ci.orono.mn.us if you have any
questions on the above requirements.
Sincerely,
CITY OF ORONO
cfi dk-u
Christine Mattson
Planning Assistant
c William &Patricia Martin via email
Kelly at Shoborg Land Services via email
Lyle Oman, Building Official
enclosures
Christine Mattson
From: Robert Bean [bobbe@bolton-menk.com]
Sent: Tuesday, September 30, 2014 1:53 PM
To: Christine Mattson
Cc: Andrew Mack; Melanie Curtis; David P. Martini; Brian Simmons
Subject: 2014-01034-2380 Watertown Road
Christine,
I have completed review of the Building Permit application package for the proposed improvements at 2380 Watertown
Road. Following are my comments for your consideration:
1. Siltfence should be indicated down gradient from the proposed work. The siltfence should be installed by the
contractor and inspected by the City prior to any work. The contractor must provide minimum 24 hour notice
prior to inspection.
2. A financial security of$2,500 from the Applicant is recommended for erosion control and engineering oversight.
The financial security is intended to provide protection in the event that it becomes necessary for the City to
install or maintain erosion and sediment control within the project area and covers the cost of vegetation re-
establishment if the applicant is unable to follow through with the conditions of approval.
3. The applicant may be required to obtain Minnehaha Creek Watershed District (MCWD)approval and permitting
for their Erosion Control Rule. A copy of any approved permits or confirmation that no permit is required should
be submitted prior to any land altering activities.
If you have any questions or comments, please contact me to discuss.
Thanks,
Robert E. Bean,Jr, P.E.
LEED Green Assoc.
Water Resources Engineer
Bolton&Menk, Inc.
Consulting Engineers&Surveyors
2638 Shadow Lane,Suite 200
Chaska, MN 55318
P:(952)448-8838,ext 2892
F:(952)448-8805
email: bobbe@bolton-menk.com
www.bolton-menk.com
This email has been scanned by the Symantec Email Security.cloud service.
For more information please visit h=://www.syLnanteccloud.com
1
Christine Mattson
From: Robert Bean [bobbe@bolton-menk.com]
Sent: Tuesday, September 30, 2014 1:53 PM
To: Christine Mattson
Cc: Andrew Mack; Melanie Curtis; David P. Martini; Brian Simmons
Subject: 2014-01034 -2380 Watertown Road
Christine,
I have completed review of the Building Permit application package for the proposed improvements at 2380 Watertown
Road. Following are my comments for your consideration:
1. Siltfence should be indicated down gradient from the proposed work. The siltfence should be installed by the
contractor and inspected by the City prior to any work. The contractor must provide minimum 24 hour notice
prior to inspection.
2. A financial security of$2,500 from the Applicant is recommended for erosion control and engineering oversight.
The financial security is intended to provide protection in the event that it becomes necessary for the City to
install or maintain erosion and sediment control within the project area and covers the cost of vegetation re-
establishment if the applicant is unable to follow through with the conditions of approval.
3. The applicant may be required to obtain Minnehaha Creek Watershed District (MCWD)approval and permitting
for their Erosion Control Rule. A copy of any approved permits or confirmation that no permit is required should
be submitted prior to any land altering activities.
If you have any questions or comments, please contact me to discuss.
Thanks,
Robert E. Bean,Jr, P.E.
LEED Green Assoc.
Water Resources Engineer
Bolton & Menk, Inc.
Consulting Engineers&Surveyors
2638 Shadow Lane, Suite 200
Chaska, MN 55318
P:(952)448-8838, ext 2892
F:(952)448-8805
email: bobbe@bolton-menk.com
www.bolton-menk.com
This email has been scanned by the Symantec Email Security.cloud service.
For more information please visit http://www.symanteccloud.com
1
Christine Mattson
From: Melanie Curtis
Sent: Friday, September 19, 2014 9:49 AM
To: 'Kelly- Schoborg Land Services, Inc.'; Christine Mattson
Cc: btmartin0908@yahoo.com
Subject: RE: Martin Permit at 2380 Watertown Rd
Kelly
Thanks for the updated plans. We have not yet received plans for the new garage and will be unable to continue our
review until they are submitted.
Thanks.
Melanie Curtis 2 952.249.4627 ® mcurtis@ci.orono.mn.us
From: Kelly - Schoborg Land Services, Inc. [mailto:kelly@schoborgland.com]
Sent: Thursday, September 18, 2014 8:06 PM
To: Melanie Curtis; Christine Mattson
Cc: btmartin09O8@yahoo.com
Subject: Re: Martin Permit at 2380 Watertown Rd
Melanie & Chris,
Please ammend the building permit for Trish Martin with the attached is the revised
survey. Changes include moving the proposed garage 7 feet south and straightening it
with the east line at the 10 foot setback. We also show the septic field (as located by
the owner). Please let me know if you need paper copies mailed or if there are any
questions or requests regarding the proposed details on the survey. The survey is to
be printed on 11 x17 paper at 100% scale (not "fit to page"). Thank you.
Kelly Brouwer
Schoborg Land Services, Inc.
763-972-3221 (office)
763-442-2715 (mobile)
kelly a�SchoborgLand.com
From: "Kelly - Schoborg Land Services, Inc." <kelly(a-.schoborgland.com>
To: Melanie Curtis <MCurtis(o)ci.orono.mn.us>; Chris <cmattson(0),ci.orono.mn.us>
Cc: "btmartin09O8C�yahoo.com" <btmartin09O8(a_)yahoo.com>
Sent: Friday, September 12, 2014 9:02 AM
Subject: Martin Permit at 2380 Watertown Rd
Melanie & Chris,
Attached is a copy of the survey showing the proposed garage for Trish Martin at 2380
Watertown Road. Please print the survey on 11x17 paper, and be sure to select "No
Scale" or "100%" so the printer doesn't shrink the drawing. Ms. Martin will be stopping
by city hall this morning in order to complete the permit application paperwork. Please
let me know if you need me to send paper copies of the survey to you or if you are able
to print this digital copy successfully for her application. Thank you very much!
Sincerely,
Kelly Brouwer
Schoborg Land Services, Inc.
763-972-3221 (office)
763-442-2715 (mobile)
kelly�D-SchoborgLand.com
z
RESIDENTIAL
ACCESSORY BUILDINGS
www.ci.orono.mn.us
`�kESHO t 952-249-4620
PERMIT
A permit is required for all accessory structures. An application packet may be obtained on the City's website
(www.ci.orono.mn.us)or at the City offices.
DESIGN l p " lZVP
Accessory structures 120 square feet or larger located on lots of less than 2 acres must be consistent in design
and color with the principal structure (house). Garages located within the rear yard on lots that have frontage
on a lake must have windows or other ornamental, architectural features on the wall facing the street or private
road.
SIZE
Maximum Individual Accessory Maximum Allowed Total Footprint
Lot Area Building Footprint of All Accessory Buildings
on a Property*
0.00-1.99 acres 1,000 square feet 2,000 square feet +5
2.00-3.00 acres 1,200 square feet 2,400 s uare feet
3.01--3.50 acres 1,400 square feet 2,800 square feet
3.514.00 acres 1,600 square feet 3,200 square feet
4.014.50 acres 1,800 square feet 3,600 square feet
4.51-5.00 acres 2,000 square feet 4,000 square feet
5.01-6.00 acres 2,200 square feet 4,400 square feet
6.01-7.00 acres 2,400 square feet 4,800 square feet
7.01--8.00 acres 2,600 square feet 5,200 square feet
8.01-9.00 acres 2,800 square feet 5,600 square feet
9.01 or more 1 3,000 square feet 1 6,000 square feet
*Only one accessory building may exceed 1,000 square feet.
NUMBER
Absent any other zoning requirements there is no limit on the number of accessory buildings per property.
STRUCTURAL COVERAGE/MASSING
Properties less than 2 acres in size are subject to a 15 percent structural coverage limitation. (See the
Structural Coverage information sheet.)
HARDCOVER
Properties located in Tier 1 though Tier 5 within the Stormwater Quality Overlay District are subject to
hardcover regulations. These are typically properties within 1,000 feet of lakes or 300 feet of certain creeks.
(See the Hardcover information sheet.)
Reference: City Code Sections 78-1279, 78-1288, 78-1404. 78- This is an information sheet.Every effort has been made to
1405, 78-1435 through 1438 insure the accuracy of the information contained herein,
however,if any information is not consistent with provisions of
January 2013 the City Code,the Code provisions will prevail.
Page 1 of 4
WELLS&SEPTIC SYSTEMS
An accessory building must be at least 3 feet (including overhangs) from a well; 20 feet from the drainfield and
10 feet from other parts of the septic system.
LOCATION
An accessory building must be at least 10 feet from the house (including a deck or overhang) and 10 feet from
any other structure. It may not be placed in a drainage, utility or similar easement.
Non-lakeshore lots:
An accessory building may not be placed closer to the street than the house. On a comer lot this requirement
applies to the narrower street frontage regardless of which frontage the front of the house faces or the address
of the house; principal building setbacks may be required. Special setbacks and approval apply to a "through
lot" (a lot with a street to both the front and back.) Contact the Planning and Zoning Department for more
information.
Setbacks for an accessory b ilding of less than 750 square feet
Zoning District Interior Side Street Side* Garage- Other-
Rear Rear
R-1A 10' 35' 10' 5'
R-1 B 10' 15'** 10' 5'
LR-1A 10' 50' 10' 5'
LR-1 B 10' 35' 10' 5'
LRA C or LRA C-1 10' 15'** 10' 5'
RR-1A 10' 100' 10' 5'
RR-1 B 1 10' 1 50' 1 10' 5'
Setbacks for an accessory b 11ding of 750 to 1,000 square feet
Zoning District Interior Side Street Side* Rear
R-1A 15' 35' 15'
R-1 B 15' 15'** 15'
LR-1A 15' 50' 15'
LR-1 B 15' 35' 15'
LRA C or LRA C-1 15' 15'** 15'
RR-1A 15' 100' 15'
RR-1 B 15' 50' 15'
Setbacks for an accessory b ilding of more than 1,000 square feet
Zoning District Interior Side Street Side* Rear
R-1A 30' 35' 15'
R-1 B 30' 30' 15'
LR-1A 30' 50' 50'
LR-1 B 30' 35' 30
LRA C or LRA C-1 30' 30' 30'
RR-1A 50' 100' 100'
RR-113 30' 1 50' 1 50'
This setback applies to unimproved street right-of-ways as well as to improved streets."Must be 30 feet if a detached garage with overhead door
facing the street side.
Reference: City Code Sections 78-1279, 78-1288, 78-1404. 78- This is an information sheet.Every effort has been made to
1405, 78-1435 through 1438 insure the accuracy of the information contained herein;
however,if any information is not consistent with provisions of
January 2013 the City Code, the Code provisions will prevail.
Page 2 of 4
(�-)2— 0 DATE TIME •
CITY OF ORONO (ALLED IN
INSPECTION NOT ESCHEDULED
_
PERMIT NO. 1 WMPLETED I�
ADDRESS 2� n 1A�1 �I�T I}�11
OWNER TELEPH NE NO.
CONTRACTOR ala
DESCRIPTION �a �O
W ❑ FOOTING ❑ DEMO-FINAL ❑ SEP C FINAL
Q ❑ POURED WALL ❑ PLUMBING RI ❑ EXCAV/GRADING/FILLING
Q ❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ TREE REMOVAL
Z
RADON SLAB ❑ MECHANICAL RI ❑ SITE INSPECTION
Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ PROGRESS
❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ COMPLAINT
Q ❑ FINAL ❑ WATER HOOK-UP ❑ FOLLOW-UP
W ❑ AS BUILT-SURVEY ❑ SEWER HOOK-UP ❑ HARD COVER REMOVAL
J ❑ DEMO-SITE ❑ SEPTIC INSTALL ❑ FOUNDATION/REMOVAL
WCONTRACTOR TO MEET YOU:_YES_NO
COMMENTS:
0
✓' r4,v
1r
W
°C b d fit
fE Cis r In, ✓
Q
2 � ,P177y r�� Q vrr,G�.e✓` ,b6/�' � � 6,C � �c6 t�
W /
P/Dl��i�G 4�y�G/tI I� As le� WGA LJ it Sate A
LU ❑WORK SATISFACTORY:PROCEED //Q S 4 ❑ PROJECT COMPLE�
O�RECT WORK&PROCEED �G�_ ®15�4���`efl ISSUJE CERTIFICATE OF OCCUPANCY
RECT WORK,CALL FOR REINSPECTION � `l&"' ""-(, TEMPORARY
V BEFORE COVERING P, wb : W*..„ � PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. ❑ PHOTO TAKEN
INSPECTOR WILL RETURN
❑STOP ORDER POSTED.CALL INSPECTOR ❑CITATION ISSUED
❑INSPECTION REQUIRED.CALL TO ARRANGE AC ES
Go F re Gj- -6 D �_fo`ac
Call for the next inspection 24 hours in advance. (952) 249-4600
Owner/Contractor on site:
Inspecto
White Copynnspectoes File Canary Copy/Site Notice
V
DATE TIM
CITY OF ORONO CALLED IN
INSPECTION NOTICE SCHEDULED
PERMIT NO. Z014-(V CLy COMPLETED
ADDRESS 2-3g'C)
OWNER TELEPHONE NO.
CONTRACTOR / �S G -6 —
3Z DESCRIPTIONIV
-
w ❑ FOOTING ❑ DEMO-FINAL ❑ SEPTIC FINAL
Q ❑ POURED WALL ❑ PLUMBING RI ❑ EXCAV/GRADING/FILLING
Q ❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ TREE REMOVAL
Z ❑ RADON SLAB ❑ MECHANICAL RI ❑ SITE INSPECTION
Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ RATED WALLS
❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ COMPLAINT
Q El FINAL El WATER HOOK-UP ❑ FOLLOW-UP
Wl BUILT-SURVEY ❑ S WER HOOK-UP ❑ FOUNDATION/REMOVAL
M -SITE ❑ PTIC INSTALL
OWN NTRACTOR TO MEET YOU: YES_NO
y ENTS:
W
a
O
O
O
Lu
cc
Q
2
W
Lm
2
J
W ❑WORK SATISFACTORY:PROCEED X14ROJECT COMPLETE
Cr ❑CORRECT WORK3 PROCEED UE CERTIFICATE OF OCCUPANCY
w
O ❑CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
V BEFORE COVERING PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. ❑ PHOTO TAKEN
INSPECTOR WILL RETURN
❑STOP ORDER POSTED.CALL INSPECTOR El CITATION ISSUED
❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call for the next inspection 24 ho in advance. -4600
OwnerR.ontractor on site:
Inspector.
White Copyllnspector's File Canary Copy a Notice
�oft � �•l !/{tDATE TIME
OF OAONO 1 CALLED IN
INSPECTION NOTICE SCHEDULED
PERMIT NO. 2t4 - COMPLETED
ADDRESS Wa xroy _ R�
OWNER TELEPHONE NO.
CONTRACTOR �,{
DESCRIPTION —AA— y 1st 4—
W ❑ FOOTING ❑ DEMO-FINAL ❑ SEPTIC FINAL
Q ❑ POURED WALL ❑ PLUMBING RI ❑ EXCAV/GRADING/FILLING
❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ TREE REMOVAL
Z ❑ RADON SLAB ❑ MECHANICAL RI 161TE INSPECTION
Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ PROGRESS
[:1 INSULATION [I WOOD BURNER/FIREPLA ❑ COMPLAINT
Q ❑ FINAL ❑ WATER HOOK-UP ❑ FOLLOW-UP
AS BUILT-SURVEY ❑ SEWER HOOK-UP ❑ HARD COVER REMOVAL
_ ❑ DEMO-SITE ❑ SEPTIC INSTALL ❑ FOUNDATION/REMOVAL
Z OWNERICONTRACTOR TO MEET YOU:_YES_NO
ti COMMENTS:
ac
W
W
G c.v Y
fh �vrr ew
iLZ �S �4
W
Q
W
W
cc
J
W ❑WORK SATISFACTORY.PROCEED OJE
W CT COMPLETE
Lu ❑CORRECT WORK A PROCEED 0 ISSU CERTIFICATE OF OCCUPANCY
CA ❑CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
V BEFORE COVERING PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. ❑PHOTO TAKEN
INSPECTOR WILL RETURN
CITATION ISSUED
❑STOP ORDER POSTED.CALL INSPECTOR
❑INSPECTION REOUIRED.CALL TO ARRANGE ACCESS.
Cali for the next inspection 24 hours in advance. (952) 249-4600
OvmerfContra site:
Inspector•.
White CopyAnspectoes File Canary CopylSite Notice
6,9- 1' PATE TIME
CITY OF ORONO CALLED IN (3
INSPECTION TIC ' / SCHEDULED "' 4`^
PERMIT NO. O � �' C MPLETED !�(
ADDRESS 2 �� jh '
OWNER TELEPHONE NO. Io
CONTRACTOR
DESCRIPTION D'
W 'FOOTING ❑ MBING FINAL f ❑ EXCAV/GRADING/FILLING
� _*PIOURED WALL ❑ MECHANICAL RI ❑ LAKESHORE/WETLANDS
y ❑ FRAMING ❑ MECHANICAL FINAL ❑ TREE REMOVAL
Z ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ SITE INSPECTION
Q ❑ RADON SLAB ❑ WATER HOOK-UP ❑ PROGRESS
❑ FINAL ❑ SEWER HOOK-UP ❑ COMPLAINT
v ❑ DEMO-SITE ❑ SEPTIC MAINT. ❑ FOLLOW-UP
Cl DEMO-FINAL ❑ SEPTIC INSTALL ❑ HARD COVER REMOVAL
Zi
v ❑ PLUMBING RI ❑ SEPTIC FINAL ❑ FOUNDATION/REMOVAL
Q OWNERICONTRACTOR TO MEET YOU:_YES
2 '
y COMMENTS: 40016"Gar tfsf 41"Ce 41/ 444.k J! 774-t,c. ,y-C
W
Wjdg_ rtK4,V�P
/ I� •
r .[ ! I
SvtL - crk AQ"a L'4n /,0b'e -e —as
W /,_ IL
IxQ - c`1�cG a r� vi 1
bIQGJ- -e r D� • ¢ac� -etirrt�it�n, C��ar
f0/ relacr -ice _
W ❑WORK SATISFACTORY:PROCEED ❑PROJECT COMPLETE s4 ,
*: /AOFIRECT WORK&PROCEED ❑ISSUE CERTIFICATE OF OCCUPANCY
uj O611,❑CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
CI BEFORE COVERING PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. ❑PHOTO TAKEN
INSPECTOR WILL RETURN ❑CITATION ISSUED
❑STOP ORDER POSTED.CALL INSPECTOR
❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call for the next inspection 24 hours in advance. (952) 249-4600
OWnerlContractor on site:
Inspector.
41
White Copyllnspector's File Canary Copy/Site Notice
< OF ORONO CALLED IN DATE TIME /
`
INSPECTION NOTICE SCHEDULED
l /(o'/S
PERMIT NO.(2 01 01031 COMPLETED
ADDRESS 2 in
OWNER TELEPHONE NO. Z_-7 lo1ft
CONTRACTOR
DESCRIPTIONr�
❑ FOOTING El PLUMBING FINAL ❑ EXCAV/GRADING/FILLING
Q ❑ POURED WALL ❑ MECHANICAL RI ❑ LAKESHOREIWETLANDS
y ❑ FRAMING ❑ MECHANICAL FINAL ❑ TREE REMOVAL
Z ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ SITE INSPECTION
Q ❑ RADON SLAB ❑ WATER HOOK-UP ❑ PROGRESS
❑ FINAL ❑ SEWER HOOK-UP ❑ COMPLAINT
v ❑ DEMO-SITE ❑ SEPTIC MAINT ❑ FOLLOW-UP
❑ DEMO-FINAL ❑ SEPTI I TALL ❑ HARD COVER REMOVAL
v ❑ PLUMBING RI ❑ SEPTI INAL ❑ FOUNDATION/REMOVAL
Z OWNERICONTRACTOR TO MEET YOU: YES_NO
COMMENTS:
W
Q.
� s
J
O
s
0
W
Q
Z
W
Z
W
cc
j
W ❑WORK SATISFACTORY:PROCEED ❑ PROJECT COMPLETE
Cr ❑CORRECT WORK&PROCEED ❑ ISSUE CERTIFICATE OF OCCUPANCY
XRRECT WORK,CALL FOR REINSPECTION TEMPORARY
FORE COVERING PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. ❑ PHOTO TAKEN
INSPECTOR WILL RETURN
❑CITATION ISSUED
❑STOP ORDER POSTED.CALL INSPECTOR
❑INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call for the next inspection 24 hou in advance. - 600
Owner/Contractor on site:
Inspector.
White CopylInspector's File Canary Copy/Site Notice
ORONO MIRY
Building Permit Survey Prepared for: Trish Martin
70
0A A.9 01
S 89 25'10" E 181.-
33.0
Oty Of1101,* -N. Line • the S. 306 ft.
Planning Zonig. Plan Review� C
Site Plan leviev f Date: io 16-0-
ED
e2rAPPRC
D �64VISloil�Qsee notes)
0 APPR M TPH 1041�6
E NIE
3 DEJ
8L 214.0
----------
Approximate septic field
N
location,
-(per owner)
0 - — - — - — -
AO
AO 4.
V-
Fence
Lr)
%
Q)
Ole.
g
En '"'! 0
A5.
Q) 29.1 L rl 4-
A
Site Address:
2380 Watertown Rd
Q)
Orono, MN 55356
Shed
0
Proposed B
Silt Fence enchmark:
Rim of manhole 66ft.-±
0�
'110 NWly of NW lot corner.
IL 107 2
_(,�L,* Elevation 7076.67
'?2 _�i 0 7.5) 0 7.
3,77
10960,
1 1
86.9 -----------
19:5 1Q)ProposedlG
�0 10
arage
Deck
i /ui i Proposed Elevations:
C1q 22.0 (P- a I
him. 71-
( 91- 519, T M. .. . Garage Floor = 1019.5
7 cv/ /� 0.
I �0�9 uNj/ 18.0 0 (1019J)'-0 (1019.
if
YIS Pro rwy
/louse
(0 Q
=10 1 C14 Note: Proposed
10 grading & proposed
36.5 silt fence designed
11P
by o th er.
toop-1
0 CJ L P0 vers
JL
& Step
Ao
0.6
,,?.o.6
02.0
q-
�Oo�.o
0.
00.6 S 89'25'10" E 181.-0.1,
Ar*
RECEIVED
-iQ?` Road
ertown Q)
-SWcorner �019.5i --Edge of Bituminous
OCT U i 2014
of the SW Y4
'-S. Line of the SW!14 Sec. 34-118-2,3
10.5 —CITY OF ORON
Cen terline
Existing Hardcover* (sa. ft.) Proposed Hardcover* ft. Boundary Description (supplied by client)
House 1454 Proposed Garage 528 The West 214 feet of the South 306 feet of the
Sher-is 420 House 1454 Southwest Quarter of Section 34, Township 1118,
Gravel Driveway 7126 Sheds 420 Range 23, Hennepin County, Minnesota. Subject to
Deck 394 Gravel Driveway 1126 right of way and any all easements of record.
Stoop & Step 32 Proposed Driveway 578 Legend
Po vers 44 Deck 394
Concrete 133Stoop & Stop 32 0 Found Iron Monument
Landscape Rock 455 Pavers 44 @ Cost Iron Monument
4,058 Concrete 131
Landscape Rock 455 X 000.0 Existing Elevation SCALE
Lot (outside R.O.W) 49,416 5,164 (000.0) Proposed Elevation 0 1 1 5 3 1 0
Eg Coble Pedistal
Total Hardcover 8.27. Lot (outside R.O.W) 49,416 Power Pole
1 inch 30 feet
*Hardcover calculated only over area outside of rood R.O.W. Total Hardcover 10.57, Vent Pipe
Job Number: 7855
hereby certify that this certificate of survey was
SCHOBVIDNEIG- prepared by me or under my direct supervision and Book/Page: 78153
that / am a duly Registered Land Surveyor under the
LA D SERVICES lows of the State-)of Minnesota. Survey Date: 913114
C) Drawing Name: mortin.dwq
INC. ----- Paul B. Schoborg --- Drown by. DMS
Note: Bearings based on assumed datum.
763-972-3221 8997 Co. Rd. 13 SEDate: Revisions. 9-18-14 (move prop. garage,
www.SchoborgLand.com Delano, MN 55J28 Registration No. 14700 odd septic field), 10-07-14 (silt fence)
Planning & Zoning
Department
Memo
To: Finance Department
From: Christine Mattson, Planning Assistant
CC: Street File
Date: August 13, 2015
GIL: 101-22205
Re: Escrow Refund
Building Permit#2014-01034 pertaining to 2380 Watertown Road is complete. Please refund
$2,500 to the property owner Patricia Martin.
The following is attached:
• Original signed escrow agreement
• Copy of cash register receipt showing escrow amount received
Mail to: Patricia Martin
2380 Watertown Road
Long Lake, MN 55356
wAstreet fileMwatertown rcA2380\escrow refund 2014-01034.doac
BUILDING PERMIT ESC GRE5ME Ll
Orono Building Permit# I (/J 1
AGREEMENT made this��day of I`r �0A, by and between the CITY OF ORONO,
a Minnesota municipal corporation ("City") ("Owners").
Recitals
1. A building permit application has been filed for a building permit, located at 2380 Watertown Road
the ("Subject Property"), legally described as The West 214 fee of the South 306 feet of the Southwest Quarter of
Section 34, Township 118, Range 23, Hennepin County, Subject to right of way and any all easements of record.
2. Owners request the City to review this application.
3. The City will commence its review of the application and incur costs associated with said review
only if the Owner establishes an escrow to ensure reimbursement to the City of its costs.
NOW THEREFORE,THE PARTIES AGREE AS FOLLOWS:
1. DEPOSIT OF ESCROW FUNDS. Contemporaneously with the execution of this Escrow
Agreement, the Owners shall deposit$2,500 with the City. All accrued interest, if any, shall be paid to the City to
reimburse the City for its cost in administering the escrow account.
2. PURPOSE OF ESCROW. The purpose of the escrow is to guarantee reimbursement to the City
for all out-of-pocket costs the City has incurred (including planning, engineering, in excess of $500, or legal
consultant review) or will incur in reviewing the plan. Eligible expenses shall be consistent with expenses the
Owners would be responsible for under a building permit application. The escrow will also guarantee
reimbursement to the City for all out-of-pocket costs the City has incurred to assure that the work is completed in
accordance with the Stormwater Pollution Prevention Plan and the provisions of Orono City Code Chapter 79.
The financial security may also be used by the City to eliminate any hazardous conditions associated with the
work and to repair any damage to public property or infrastructure that is ca ed ,by the w k including planning,
engineering, or legal consultant review) associated with building permit # U1�^ if compliance with
the approved building permit is not accomplished.
3. MONTHLY BILLING. As the City receives consultant bills for incurred costs, the City will in turn
send a bill to the Owners. Owners shall be responsible for payment to the City within 30 days of the Owners'
receipt of bill.
4. DISBURSEMENT FROM ESCROW ACCOUNT. In the event that the Owners do not make payment
to the City within the timeframe outlined in #3 above, shall issue a Stop Work Order until the Owners pay all expenses
invoiced pursuant to #3. The City may draw from the escrow account without further approval of the Owners to
reimburse the City for eligible expenses the City has incurred.
5. CLOSING ESCROW. The Balance on deposit in the escrow, if any, shall be returned to the
Owners when all requirements related to the project are complete. City Staff shall review the terms of this escrow
agreement two times per year to determine whether the requirements of the project have been successfully
completed and whether it is appropriate to return the funds. Owner may also request the release of the funds,
and such funds shall be released upon City Staff receiving the appropriate verification that all requirements of the
project have been successfully completed.
6. CERTIFY UNPAID CHARGES. If the project is abandoned by Owners, or if the eligible expenses
incurred by the City exceed the amount in escrow, the City shall have the right to certify the unpaid balance to the
subject property pursuant to Minn. Stat. §§415.01 and 366.012.
CITY: CITY OF ORONO OWNER:
By
Its:
City o{ mo
2?`5 ' ie), Parkway
Oro' HN 55356 952-249-4600
Receipt No: 3.011772 Sep 12, 2014
t
Patricia Martin
Previous Balance: I
Permits .00
2014-01035 for Garage 2.500.00
Permit #2014-01034
101-22205
Deferred Rev-Developer Deposit '
Total:
2,500.00
;
Check
Check No: 3637 2,500.00
Payor:
Patricia Martin
Total Applied: 2,500.00
Change Tendered:
.00
09/12/2014 11:00AM=
CITY OF ORONO * 2014 - 01035 *
2750 KELLEY PARKWAY DATE ISSUED: 09/12/2014
ORONO,MN 55356-
952 249-4600 FAX: 952 249-4616
ADDRESS 2380 WATERTOWN RD
PIN 34-118-23-33-0004
LEGAL DESC UNPLATTED 34 118 23
LOT 000 BLOCK 000
PERMIT TYPE ESCROW FEE-APPLICANT
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE ESCROW FEE-APPLICANT
NOTE: ESCROW FOR BUILDING PERMIT#2014-01034 FOR A DETACHED GARAGE,PD BY OWNER CK#3637$2,500.00
APPLICANT ESCROW FEE-APPLICANT 2,500.00
MARTIN,WILLIAM&PATRICIA Payment(s) TOTAL 2,500.00
2380 WATERTOWN RD CHECK 3637 2,500.00
LONG LAKE,MN 55356-
OWNER
MARTIN, WILLIAM&PATRICIA
2380 WATERTOWN RD
LONG LAKE,MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be performed according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked at any time for due cause.
pdy)-�� mdt� ';�7--/
Applicant Permitee Signature Date Issued By Signat6re Date