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Home My WebLink AboutPermit not issued per applicant N D� I 5 � u� ��►� �� Total Fee: $ � � . �''�� Date Received: '� �a-1 C� Entered By: Permit#: 1"��`� 9�9 CT'T'`' � TO - BUILDING PERNIIT APPLICATION '�,�-, `��_� ,,�,�.F.,; � � �� submitted in full before plan review will be started. �5 � ,nc\ti. ;� �� ,�, ?l � please print all information) ------ 5� �,P�'nS � ------------ ---------- - -------------------------------------------------- \�V�� THE i � �`' � ��nF"� � � one) OWNE R CONTRACTOR ��' � ,\c•� i- �, JOB 5 � .��_��: (o,�O • �' ZIP: ��5 NAME OF OWNER: ��*�r�� Qy��y/��✓r�� PHONE: (home) �� `�Z/9 (work) �� MAILING ADDRESS: ,d,g �S� CITY: a��^ ZIP: .�;��S CONTRACTOR: PHONE: CONTACT PERSON: MOBILE/PAGER: MAlLIl�G ADDRESS: CITY: ZIP: STA"TE LICENSE: # ARCHITECT/ENGINEER: �i n�P ITih�tx ,p�}i�`� PHONE: 9��' 7�� MAILING ADDRESS: �b �,(�, 7$ S�. .��;�r?/dCITY: �/��;h��,��k ZIP: � NAME: REGISTRATION# TYPE OF WORK: New Addition X Accessory Structure Move Remodel/Alteration Land Alteration PR POSED VyORK (describe in detai�: i �a�t ,�(� ✓ �� v � Z � s , e /vr s . STORIES: � SQ. FEET OF EACH FLOOR: Z�(�• NO. OF BEDROOMS: � GARAGE STALLS: ATT. DET. ESTIMATED CONSTRUCTION VALUATION (excluding land): $ ��, d(�.� I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in conformance with the ordinances and codes of the City and with the State Building Code; that I understand this is not a permit and work is not to start without a permit; and that the work will be in accordance ith the approved plan. APPLICANT'S SIGNATURE: � � DATE: Z 0 NOTE! Parade o�Homes events require separate permit approval by Police Department and City Council 60 days prior to the event. Non permitted events will not be allowed. 9 � r Sea 13.04 RIGHTS OF SUBJECTS OF DATA Subd. 1. Type of data. The rights of individual on whom the data is stored or to be stored shall be as set forth in this section. Subd.2. Information required to be given individual. An individual asked to supply private or confidential data concerning hunself shall be informed of: (a)the purpose and intended use of the requested data within the collecting state agency,political subdivision, or statewide system; (b) whether he may refuse or is legally required to supply the requested data; (c)any known consequence arising from his supplying or refusing to supply private or confidendal data; and(d)the identiry of other persons or entities authorized by state or federai law to receive the data. This requirement shall not apply when an individual is asked to supply investigative data, pursuant to section 13.82, subdivision 5, to a law enforcement officer. The comtnissioner of revenue may place the notice requued under this subdivision in the individual income tax or property tax refund instruccions instead of on those forms. Subd.3. Access to data by individual. Upon request to a responsible authority,an individual shall be informed whether he is the subject of stored daha on individuals,and whether it is classified as public,private or confidential. Upon his further request, an individual who is the subject of stored private or public data on individuals shall be shown the data without any charge to him and, if he desires, shall be informed of the content and meaning of that data. After an individual has been shown the private data and informed of its meaning, the data need not be disclosed to him for six months the�eafrer unless a dispute or action pursuant to this section is pending or additional data on the individual has been collected or created. The responsible authority shall provide copies of the private or public data upon request by the individual subject of the data. The responsible authoriry may require the requesting person to pay the actual costs of making, certifying, and compiling the copies. The responsible authority shall comply immediately, if possible,with any request made pursuant to this subdivision, or within five days of the date of the request,excluding Satuidays,Sundays and legal holidays, if immediate compliance is not possible. If he cannot comply with the request within that rime,he shall so inform the individual, and may have an additional five days within which ro comply with the request, excluding Saturdays, Sundays and legal holidays. Subd.4. Procedure when data is not accurate or complete. M individual may contest the accuracy or completeness of p�blic or private data conceming himself. To exercise this right, an individual shall notify in wriring the responsible authority describing the nature of the disagreement. The responsible authoriry shall within 30 days either: (a)correct the data found to be inaccurate or incomplete and attempt to notify past recipients of inaccurate or incomplete dara, including recipienu named by the individual;or(b)notify the individual that he believes the data to be correct. Data in dispute shall be disclosed only if the individua('s statement of disagreement is included with the disclosed data. The determination of the responsib(e authority may be appealed pursuant to the provisions of the administrative procedure act relating to contested cases. DATA PRIVACY ADVISORY In accordance with M.S. 13.04, Subd. 2, "Rights of subjects of data", we would 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 pernut 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 M.S. 13.04 (available upon request) to review private data on yourself. 6. Your full name is required to process this application or pernut. First Middle Last Address Ciry State Zip Phone I un 'rst my ri hts as state ove. � � � C., fl/ S ture 10 � CHECK OFF LIST FOR ISSUANCE OF PERMITS FOR OFFICE USE ONLY ADDRESS OR LEGAL: (o S v N 0 61�W N i��D PID: DESCRIP'TION OF WORK: /a Q�J�� --------------------------------------- ------- ----------------------------------------------------------------------- ZO\ING REVIEW BY: DATE APPROVED: �7—6 -6� BUILDING REVIEW BY: DATE APPROVED: �_ 6 ��v FEES TO BE CHARGED: Misc. Fees Calculated By: PERMIT Yes �/ No PLAN REVIEW Yes �/ No SEWER CONNECTION STATE SURCHARGE Yes ✓ No WATER CONNECTION INVESTIGATION FEE Yes No PARK FEE SAC Yes No SITEINSPECTION Number of SAC Units OTHER (specify) ------------------------------------------------------------------------------------------------------------------------ ZONING CHECK LIST Zoning District: �-2' 1 J9 Fire Department: (:o,uc. (p1c..� Post Office: (,�ivc,U-IC.v School District: t�2-e�0 ,�—�_ Lot Area: Sq.ft. Acres 3.g3 Width Depth Survey Submitted: Yes sL No Date of Survey: 3-2�-5�� Proposed Setbacks: �snt (Lake): 3Q�Q ' Right Side: 3v-3 � �ear (Street): 63 Z Left Side: 1�Z. Adjacent Structures: �7'T'�c,(-r,...� Wetland: /v�/� Building Height: Def. Hgt. C�� G Peak Hgt. Lot Coverage: /✓//'* Grading: Staff Approval Date: — By: -� Council Approval Date: '—' Septic: Staff Approval Date: �-- By: — Zoning File: # 2J� Resolution: # �/33Z- Resolution Date: Shoreland District: Avg. Setbac : ll A-2c q„n.� Bluff Setback: N� �- I.ot Coverage: N� p� Existing Proposed Hardcover: 0-75' �s-Zso� �, �� 250-500' 500-1000' Hardcover Variance Required: Yes No L Date of Council Approval: REMARKS (in house): 27 � BUILDING REVIEW CHECK LIST UBC: �- '� CONSTRUCTION TYPE: �� Sq Footage $ Per Sq Ftg Basement x = lst Floor x = 2nd Floor x = Garage x = x = TOTAL � Estimated Construction Value: $ 30, O��" Inspections Required: Work Requiring Separate Permits: Site p�Plumbing Fire Hardcover Removal o�Mechanical Water Connection _�Footing Septic Sewer Connection o�Framing Fireplace Lawn Irrigation _�i Insulation (Masonry) Other _�Wall Board (Mfg.) Well (State Permit) ,�Final Grading/Filling �Electrical (State Permit) Other REMARKS (IN HOUSE): ------------------------------------------------------------------------------------------------------------------------ REVIEW BY OTHERS: DATE: Access: Existing New Access Approval: Date By: ------------------------------------------------------------------------------------------------------------------------ REMARKS (TO BE NOTED ON PERMII�: 28