HomeMy WebLinkAboutpermit application �-�" �;�1�� +�s"�--�P � �r � �..1�
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Total Fee: $ � Date Received: `"�- /Z-�-��� �....J (� �
Entered By: Permit#: t(L �'4-.C�
CITY OF ORONO - BUILDING PERMIT APPLICAT�ON
All information must be submitted in full before plan review�l be started.
(please print all information) ,'
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THE APPLICANT IS: (circle one) OWNER R CO RACTOR
f� �) � C�
JOB SITE ADDRESS: `1����G!`7 ��'Of��� ��v ZIP: ����� /
/
Will this be a Parade of Homes, Remodelers Showc�e Home or other Display Home?
❑ Yes �NO If yes,a special event pe�•rnit is requir�d with Police Department and City Council app�roval
60 days prior to the event. Shirttle b�zs service rvill be regziired a�nless applicant demon.strates
sufficient on-site parking is availcrble. Non yermitted events will not be allowed.
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NAME OF OWNER: t)//f'L C�(�/2�ii� PHONE: (home) ����� �Y�6���G%
• (work)��2•:,��S`-�!7 0�i
MAILING ADDRESS: `7'�5��/i,r�iy,� �ti CITY: ��Un� ZIP: �
.,
CONTRACTOR: Cl�< ���.,. PHONE:
CONTACT PERSON: ` MOBILE/PAGER:
MAILING ADDRESS: CITY: ZIP:
STATE LICENSE: # EXPIRATION DATE:
ARCffiTECT/ENGINEER: '`'� PHONE:
MAILING ADDRESS: ��t CITY: ZIP:
NAME: 12�GISTRATION: #
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TYPE OF WORK: New Addition X Accessory Structure �
Move Home Remodel/Alte�,ation
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PROPOSED WORK(describe in detai�: �J/.��D G��/�1l/�C��`�r;G-' G�/011k'%��'s�
STORIES: � SQ.FEET OF EACH FLOOR: �C'�' ��
NO. OF BEDROOMS: � GARAGE STALLS: ATTACHED DETACHED_
:
�l�'�-G' `�
ESTIMATED CONSTRUCTION VALUATION(excluding land): $ )v,ci�U �'��
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I hereby apply for a building permit and I acknowledge that the information above is complete and ccurate;
that the work will be in conformance with the ordinances and codes of the City and with the State�ilding
Code;that I understand this is not a permit and work is not to start without a permit;and that the work�11 be
in accordance with the approved pla �,
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APPLICANT'S SIGNAT . DATE: ���Q� �'
31
Sec.13.04 RIGHTS OF SUBJECTS OF DATA
Subd. 1. Type of daca. 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 confidcntial data conceming himselfshall 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 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 investiga[ive data,pursuant to section 13.82,subdivision 5,to a law enforcement officer.
The commissioner of revenue mayplace the notice required under this subdivision in the individual income tax or property tax refund
insttuctions instead of on those forms.
Subd.3. Access to data by individual. Upon request to a responsible authority,an individual sha(1 be informed whe[her he is the subject of
stored data on individuals,and whether it is classified as public,private or confidential. Upon his fiirther 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 infonned of the content and
meaning of that data. After an individual has been shown the private data and informed of its meaning,tlte data need not be disclosed to him for six
months thereafter unless a dispute or action pucsuant 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 subjec[of the data. The responsible authority
may require the requesting person to pay the ac[ual costs of making,certifying,and compiling the copies.
The responsible authority shall comply immediately,ifpossible,with any request made pursuant to this subdivision,or within five days of
the date of the request,excluding Saturdays,Sundays and legal ho(idays,if immediate compliance is not possible. If he canno[comply 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 ho(idays.
Subd.4. Procedure when data is not accurate or complete.An individual may contest the accuracy or completeness ofpublic or private data
concerning himsel£ To exercise this right,an individual shall notify in wiiting 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 recipients of
inaccurate or incomplete data,including recipients named by the individual;or(b)notify the individual that he believes the data to be cotrect. Data in
dispute shall be disclosed only if the individual's statement of disagreement is included with the disclosed data.
The determination of the responsibla authority may be appealed pursuant to the provisions of[he 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 fumish 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 suppiy 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
� ►►'YL._ � ��0 2r�!(C��L
Address
y��5 C�n �PG'�w� �-v �
City ��Gn/�� j State Zip �-3�� Phone ��� �(L( '�(--�J� 7�'
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I understand y rights as stat� ve.
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Signatur
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