HomeMy WebLinkAbout2001-P03487 - addn/remodel/repair ` PERMIT
CITY OF ORONO
2750 Kelley Parkway - PO Box 66 Permit Number: Po3as�
Crystal Bay, Minnesota 55323 P@fC111t Typ@: Addition/Remodel/Repair
(952) 249-4600 Date Issued: 2isi2oo�
SITE ADDRESS: 1120 Cox Farm Rd
LONG LAKE, MN 55356
P I D: 27-118-23-31-0021
DESCRIPTION: UBC Occupancy R3
Construction Type VN
Proposed Use: Kesidentiai
Census Code 434
Permit Class: Building
Permit Type: Addition/Remodel/Repair Permit Sub-type(s): Addn/Remodel/Repair
DETAILS:
Approved per resolution#:
Separate permits required: riumoing iviecnanic;ai r,iecuicai �siaiej
NOTICES/REMARKS:
FEE SUMMARY: Permit Fee: $ 153.25 Valuation: $ 7,500.00
Plan Review Fee: $ 99.58
State Surcharge Fee: $ 3.75
TOTAL FEE: $ 256.58
APPLICANT: E[uc& LISA BERT OWNER: ERic&i.isa BExT
1120 COX FARM RD 1120 COX FARM RD
LONG LAKE,MN 55356 LONG LAKE,MN 55356
THE UNDERSIGNED HEREBY REQUESTS PERMISSION TO MAKE THE REAL IMPROVEMENTS SPECIFIED
AND AGREES TO DO ALL WORK IN STRICT COMPLIANCE WITH ALL CITY OF ORONO ORDINANCES AND
STATE OF MINNESOTA BUILDING CODE REQUIREMENTS.
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APP I ANT PERMIT E SI NATURE ISSU BY SIGNATURE
Copies: City,Applicant,Assessor, Finance Page 1
Total Fee: $ �-, ! Date Received: ���`� /� �
' Entered By: Permit#: ��.;��,��
CITY OF ORONO - BUILDING PERNIIT APPLICATION
All information must be submitted in full before plan review will be started.
(please print all information)
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THE APPLICANT IS: (circle or�e) OWNER O CONTRACTOR
JOB SITE ADDRESS: �
I/�U �ox �i^.rr"t d�c� (�; ,.-�c; ZIP: SS,3��>
NAME OF OWNER: �;i c_ �' L.�5� ���� PHONE: (home)�iS� -`>`I z -`�3sy
(work) 7G� �- y��i - S ��� "�
MAILING ADDRESS: 5�..r-,-� CITY: ZIP:
CONTRACTOR: L-r-�� --f ������ _. _ ,- . PHONE: �a•�-�z
CONTACT PERSON: F_ r-�L- t 1 . ; �.z r-i� MOB.�I,E'/PAGER: (,/�Z ��� - ��v yD
MAILING ADDRESS: ��;�-, � CITY: ZIP:
STATE LICENSE: # n/�
�.i?.�HT'1`F�,'T/F1��,T�L1V,�Fla� �'��} P�IO.�':
MAILING ADDRESS: � CITY: ZIP:
NA��TE; REGISTRATION#
TYPE OF WORK: New Addition Accessory Structure
Move Remodel/Alteration ✓ Land Alteration
PROPOSED WORK(describe in detai�: ,�� � ��-1-,`��.�,P� � -�a,�;..,G - � �,°���!e�t�n�
��t� �t ��� . � � �Pc��� T ��v�- �c�r �� � � ,' � �-t��=�L����
t(recc��'� �n �;��ac� w�.e.'1 ���.rc ha� tc hc,�t t ,�. ��50 5c ,'lt C�r�Oz�t't;/
STORIES: n/f�; SQ. FEET OF EACH FLOOR: ,�,�prcX /oZ60 �� :�-�r �r _
NO. OF BEDROOMS: 1//� GARAGE STALLS: ATT. i�,� DET.�I/r'
ESTL�VIATED CONSTRUCTION VALUATION (excluding land): $ 1,SDU� ��
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.
___� � i
APPLICANT'S SIGNATURE: � ���� �" _ i ��^� DATE: G��'U/
�•----��T=
NOTE! Parade Qf Homes events require separate permit approval by Poliee Department and
City Council 60 days prior to the event. Non permitted events will not be allowed. �
Sec.13.04 RIGH'TS OF S[IB.TECTS OF DaTA
Subd. 1. Type of data. The righ�s of individual on whom the data is stored or to be scored shall be as set for[h in this secdon.
Subd.2. Information reqirired to be given individual. An individual asked to supply private or confidendal dara concerning himself shall
be informed of: (a) [he purpose and intended use of the requesced data within the collecting"state agency, political subdivision,or sratewide system;
(b)whe[her he may refuse oY is legafiy required to suppty che requested data;(c)any Imown consequence arising from his supplying or refusing ro supply
private or confidential data;and(d)the identity of other persons or enrides authotized by state or federal law to receive the data. This requirement shall
not apply when an individual is asked to supply invesdgadve dara, pursuant ro secdon 13.82, subdivision 5, ro a law enforcement officer.
The commissioner of re�enuz mav place the nodce reauired under this subdivision in the individual income tax or propercv tax refund
instructions instezd of on those forms.
Subd. 3. Access to data by individual. Upon request to a responsible authoriry,an individual shall be informed whether he is the subject
of stored data on individuals, and whecher it is classified as public, private or confidential. Upon his funher request, an individual who is the subject
of stored private or public data on individuals shall be shown the data without any charge to hun and, if he desires, shall be informed of the content
and meaning of that data. Aftzr an individual has been shown the private data and informed of its meaning,the data need not be disclosed to hun for
six months thereafter uriless a dispute or acrion pursuan[to chis secrion is pending or addidonal data on the individual has been collected or created.
The responsiblz authoriry 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 che accual costs of making, cerafying, and compiling the copies.
The responsible authoriry shall comply immediately, if possible, with any request made pursuant to this subdivision, or within five days of
the date of[he request,excluding Sa[urdays,Sundays and leeal holidays,if immediate compliance is not possible. If he cannot comply with the request
within that time,he shall so inform the individual,and may have an additional five days within which to comply wi[h 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 pubtic or prn•ate
data conceming himself. To exercise[his rieht,an individual shall nodfy in wri[ing the responsible authoricy describing�he na[ure of the disagreement.
The responsible authoriry shall within 30 days either. (a)correcc the data found ro be inaccurate or incomplete and attempt to nodfy past recipients of
inaccurate or incomplete data, including recipien[s named by che individual; or(b)notify the individual tha[he believes the data to be correc[. Data
in dispuce shall be disclosed only if the individual's statemen[of disagreement is included with the disclosed data.
Tlte decermination of the responsible authoriry may be appealed pursuan[to the provisions of the administnrive procedure act relating to
conrested cases.
DAT:� PRIVACY ADVISORY
In accordance with M.S. 13.04, Subd.2, "RiQhts of subjects of data", we would like to inform you that your reauest
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 rocess this application or�rmit.
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First /�
iddle Las[
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Addre�ss ��,��'� � J J7�� �l S�'����������
( 'r�'l c� �
��ry State Zip Phon
I understand my rights as stated above. �
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Signamre �
' � CHEC�i OFF LIST FOR ISSUA.��TCE OF PERII�IITS
_ FOR OFFICE USE ONL,Y � .
ADDRESS OR LEGAL: 1� Z�� C�x �-,o,�2"yL n 'A-� -
PID:
DESCRIPTION OF�ORK: s L —r�r� f=i
ZO��'G R.E�:i"Eti� BY: D�TE APPROVED: z- S -� I
BUII�DItii'G REY��BY: D�.TE APPROY�D: Z- �-o�
FEES TO BE CH.4RGED: Misc. Fees Calculated By:
pERMi"I' Yes �� No :•
pI,�N REVIEW Yes ,/ No SEWER CONiYECTION
STATE SURCHARGE Yes �/ No WAT�RCONYEGTION
ir,'VESTIGATION FEE Yes No PARK�E
SAC Yes No SITEINSPECTION
Number of SAC�Units OTHER (specify)
ZOti1�TG CT�CK LIST zonin� Districc: Nv c l-{�4s1lG e
Fire Department: Post Office: School District: - �
I.ot Area: Sq.ft. Acres idch Depch
Surve,� Subu.itted: Yes No Date of Survey:
Proposed Setbac!cs:
Froat(La.�Ce): Ri�hc Side: �
Rear (Screet): Left Side:
Adjaceat S�ructures: �Vetl . •
Building Hei�hc: Def. H�t. Pea.�: ot.
Loc Covera�e:
Gradir.�: Scafi Approval Date: gy: Council Approval Date:
Septic: Staff Approval Da�e: By:
Zoain� File: fi Resolution: � Resolutioa Date: .
Shoceland District:
Av�. Secback: Btufi Setback: LotCo�'era�e:
E���? Proposed
Hardcover: 0-7�'
7�-250'
ti0-SQO'
500-1OQ0'
Hardcover Varia.nce Required: Yes No Date of Council Aoproval:
gEtiIA.R�iS (in house):
7
BUII,DING REVIEW CHECI� LIST
usc: 2�� - co�s�-xucno�r z��E: �!/�
Sq Footage S Per Sq Ftg
Sasement z =
lst Floor z =
2nd Floor z =
Gara�e z =
z =
TOTAL
Estimated Construction Value: $ -7,S d c`�
o�
Inspections Required: �Vorl:Requiring Separate Permits:
Site D( Plumbing " Fire
Hardcover RemovaI D� Mechanical Water Connection
Footin� Septic Sewer Connection
_� Framing Fireplace Lzwn Irriga[ion
p( Insulation (Masonry) O�her
_ 0��Vall Board (Mfg.) �3/ell (State Permit)
_�Final Grading/Filling �_ Electrical (State Permi[)
O�her
RE��iARKS (IN HOUSE): -
REVIEW BY OTHERS: � D:�TE:
Access: Ezistin� New
Access Approval: Da[e By;
RE�'LA.RKS (TO BE NOTED ON PERMI�:
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