HomeMy WebLinkAbout2008-00141 - void permit � CITY OF ORONO PERMIT NO.: 2008-00141
2750 KELLEY PARKWAY
ORONO, MN 55356- �ATE IssuEn:
952 249-4600 FAX: 952 249-4616
PRINTED WITHOUT ISSUING 8/26/2008
ADDRESS : 4245 CHIPPEWA LA
PIN : 31-118-23-42-0001
LEGAL DESC : LJNPLATTED 31 118 23
: LOT 000 BLOCK 000
PERMIT TYPE : ADDITION/REMODEL/REPAIR
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADDN/REMODEL/REPAIR
VALUATION : $ 4,212.00 ,`��
NOTE: FLOATING CONCRETE SLAB PATIO TO REPLACE LOOSE PAVER STONES n,� U
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NO PERMIT REQUIRED PER LYLE OMAN 8/2U08. �
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APPLICANT PERMIT FEE SCHEDULE 118.00
SINZ STAMPED CONCRETE PLAN REVIEW 76.70
271 STATE AVE. S.
NEW GERMANY,MN 55367- STATE SURCHARGE(VALUATION) 2.11
(952)220-9772 TOTAL 196.81
OWNER
ALTMAN,JON ADAMS&CLEA
4245 CHIPPEWA LA
MAPLE PLAIN, MN 55359
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be performed according to
the approved plans and specifications,applicable City approva(s,and the
State Building Code. This permi[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.
/ / / /
Applicant Permitee Signature Date Issued By Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
.�'" 5 p o �<� � o�.,.,�.t,,s
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Total Fee: $ Date Received: �' /� O �
Entered By: Permit#: o?DD�' — D p��/
CITY OF ORONO - BUILDING PERMIT APPLICATION
All information must be submitted in full before plan review will be started.
(pleuse print all informution)
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THE APPLICANT IS: (circle o OWNER CONTRACTOR
JOB SITE ADDRESS: �v� �� G�,�-j�r��: L�v ZIP: � —��..5-�
Will this be a •arade 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 dernonstrates
sufficient on-site parking is available. Non permitted events will not be allowed
NAME OF OWNER: —�/J �i-J �G���� PHONE: (home) �S� Y� ��I" �
� �
L (work) 5'S�L �/>3�D 9/
MAILINGADDRESS: � C " ��J=; CITY: f, ^� �� ZIP: Ss3S9
CONTRACTOR: �%•�% � 57��-��"�--r �o,���'' y e PHONE: �S—oZ o�� 9 77•Z
CONTACTPERSON: ,-:i, M �%..�� MOBILE/PAGER:
MAILING ADDRESS: �?/ �'�f� ��� � CITY: �l��6-P�--�<��ZIP: SS3� �
STATE LICENSE: # EXPIRATION DATE:
ARCHITECT/ENGINEER: PHONE:
MAILING ADDRESS: CITY: ZIP:
NAME: REGISTRATION: #
TYPE OF WORK: New Home Addition Accessory Structure
Move Home Remodel/Alteration (ie: Siding, Windows)
Any earth movement may require MCWD review and ermits!
PROPOSED WORK(describe in detai�: F(o�ti f;� �� ✓ c � r f� � a . a. ��
v /`� /� c C� ����s e a c;�' � -v e •— — �r .
STORIES: SQ.FEET OF EACH FLOOR:
NO. OF BEDROOMS: GARAGE STALLS: ATTACHED DETACHED
ESTIMATED CONSTRUCTION VALUATION(excluding land): $ y,�/� s �' � �� �
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 with the approved plan.
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APPLICANT'S SIGNAT �—�-^ � DATE: �µ � �� ��' �
31
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Sec.13.04 RIGHTS OF SUBJECTS OF DATA � �"
'�
Subd. L 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 orconfidential dataconcerning himselfshall be
informed ofl (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 leeally required to supply the requested data;(c)any known conseyuence arising from his supplying or refusing to supply
private or confidential data;and(d)the identity of other persons or entities authorized by state or federal 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 commissioner of revenue mav place the notice required under this subdivision in the individual income tax or prooerty tax refund
instructions 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 data on individuals,and whether it is classified as public,private or confidential. Upon his fuRher 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 con[ent and
meaning of that data. Afrer an individual has been shown the private data and informed of its meaning,the data need not be disdosed to him for six
months thereafter 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 ofthe private or public data upon request by the individual subject ofthe data. The responsible authoriry
may require the requesting person to pay the actual costs of making certifying and compiling the copies.
The responsible authority shal I comply immediately,if possible,with any request made pursuant to this subdivision,or within five days of
the date ofthe request,excluding Saturdays,Sundays and legal holidays,ifimmediate compliance is not possible. Ifhe cannotcomply with the request
within that time,he shall so inform the individual,and may have an additional five days within which to comply with the request,excluding Saturdays,
Sundays and legal holidays.
Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or completeness of public or private data
conceming himself. To exercise this right,an individual shall notify in writing the responsible authority describing the nature of the disagreement. The
responsible authority shall within 30 days either (a)correct the data found to be inaccurate or incomplete and attempt to notify past recipienu of
inaccurate or incomplete data,including recipients 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 individual's statement of disagreement is included with the disclosed data.
The determination of the responsible 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 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 M.S. 13.04(available upon request)to review private data on yourself.
6. Your full name is required to process this application or permit.
First Middle Last
Address
City State Zip Phone
I understand my rights as stated
Signature
Reset rorm 32
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CERT�ICATE OF SURVEY FOR
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IN� THE SE t/4 OF SECTION 3 t-118-23
HENNEPW CC?UNTY, MINNESOTA
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www.sinzstampedconcrete.com Alt. PhOne
271 State Ave. S. • New Germany, MN 55367
952-220-9772 How did Client learn about us `.-�r , ._s -- :_: ��> � a`ic
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*See Terms and Conditions on final price"
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Notes/Special Instructi�S� � , o
40/o Due at Start of Job
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Pattern:_ ��„��c. Color: �)G�-___ Release: �U��F t}„l, •
Crack Contr6l I WA /I DO NOT WANT (circle one)control joints.
Control joints are saw cuts or hand grooved joints located 3 to 10 feet apart.
CUENT ACCEPTANCE
l have reviewed this contract and understand the terms and cond/flons of the cOntraCt.
By signing beloyy�l ree to have the work performed.
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Signature X r�„�m Slh z� Date �" ��"��
Signature X ___ � � ��~���`_`� Date _�'- � �` ��'�"
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