HomeMy WebLinkAbout2014 - 01223 - bldg permit application CITY OF ORONO
BUILDING PERMIT APPLICATION
FOR NEW STRUCTURES OR ADDITIONS II-0/
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MailingAddress:
Box 66: Permit number: cWf 7 O/2),-)---
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0 Crystal Bay, MN 55323-0066 Date received: /0—a-/—/T
Street Address:' Received by:
ti* 1t 2750 Kelley Parkway Plan review fee:
Orono, MN 55356
�"1kESHDl- 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: p �" +
Job Site Address: la17 (U ► l.41►\uirS3' rcA, 1 Or>t"c MN' 5S 3 (Q'1-I
Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes 0 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: r-tki Z0..b,\‘ c,
State License# 61 A-, Expiration Date:
Phone: (cell) 6 S() t 9 5— 2 c�1 (office)
Mailing Address: 12A97 (A), (alv\ &r5A- Tri \ City: oro, ZIP: S '-
S 3c,
Contact Person: 4;1,kre,,., Za.L: ) Applicant is: Contractor /(omeowner� (Circle One)
Email and/or Fax: 43 z A l t'1\ ,V1 s o LA ;ors , c 0Vv\
PROPERTY OWNER INFORMATION:
Name: AA.01ttuo DI 11c,
Phone (day): off U42) 303-01120
Address: 12(17 w. I d 1' ,,r51- `T-1,:1 City: O r-�r\o ZIP: 5 S 3 6y
Email and/or Fax
ARCHITECT/ENGINEER INFORMATION:
Name:
Phone(day):
Address: City: ZIP:
Email and/or Fax:
PROJECT INFORMATION: Descri•tion of •ro•ect: e. oror Car ,w.--1--
1.Type of Project 2. Proposed Use .Structure ype 4.Sewage Disposal &
Water Supply
❑ New Construction 0 Single Family with 0 Residence
❑Addition attached garage 0 Garage/Accessory Bldg. 0 Public Sewer
g.Accessory Building 0 Single Family with 0 Deck
0 Relocation detached garage 0 Office/Commercial 0 Private Sewer
0 Other: (specify) 0 Multiple Family/Condo 0 Warehouse
0 Public 0 Storage 0 Public Water
"Any earth movement may also require 0 Commercial E Other(specify)
MCWD review&permits. 0 Industrial Tervyarw7 Car f"' 0 Private Well
Minnehaha Creek Watershed District(MCWD) 0 Other: (specify)
18202 Minnetonka Blvd
Deephaven,MN 55391
Phone: 952-471-0590
Fax: 952-471-0682
www.minnehahacreek.orq
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Estimated Construction Valuation (excluding land) $ .�
DE.�vIca — A/ o r At t5
Pi2w"cwe c9 ,v2 vem`46
.4)4, (cLtu ._ 1(- 10-Z.0141
STRUCTURE INFORMATION:
1.Structure Dimensions 1.Structure Dimensions (continued) 2.Type of Construction
a. Length (ft.)= Number of bedrooms=
❑Wood/Frame
b.Width (ft.)= l 3 Number of garage stalls: ( ❑ Masonry
Areas in square feet Attached= I=1 Metal
❑ Pole Bldg.
c.Basement= Detached=
0 ICF
d. 1st Story = Z c,O 0 On-site Prefab
e.2nd Story= 0 Off-site Prefab
f. ' Story = El Other(please specify): k
g.Total Area= Z6 0
REQUIRED SUBMITTALS:
All of the information must be submitted in order for your application to be processed:
Not
Enclosed Applicable
❑
0 Permit Application
❑
0 Proposed Building Plans
❑ 0 MN State Energy Code Calculations and Mechanical Code Requirements Form
❑
0 Survey(meeting all requirements)
❑ ❑ Stormwater Pollution Prevention Plan
❑
0 Hardcover Calculation(s)
❑
0 Septic System Site Evaluation Report
❑
0 Access Permit
❑ ❑ Wetland Buffer Improvement Plan
❑
0 Engineered Plans for Retaining Walls 4 feet or above
❑ ❑ Plan Review Fee
❑ ❑ Application Escrow&Agreement
❑
0 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.
�L 7 Date: 10 2 1 2-0/Li
Applicant's Signature:
Owner's Signature: aik—) / Date: 142 ) `L 0 I 4