HomeMy WebLinkAbout2004-P08272 - re-roof - - ,r's
CITY OF RONO PERMIT
� Permit Number:
2750 Kelley Parkway - PO Box 66 Po82�2
Crystal Bay, Minnesota 55323 Pet'mit Type: Minor Alterations
(952) 249-4600 Date Issued: i2igi2ooa
SITE ADDRESS: 190o Fox Ridge Rd
Long Lake,MN 55356
PID: 03-117-23-13-0009
DESCRIPTION:
Proposed Use: Residential
Pernut Class: Building Census Code O/S-Building
Perniit Type: Minor Alterations Permit Sub-type(s): Building-Re-Roof
DETAILS:
Approved per resolution#:
Separate permits required:
NOTICES/REMARKS:
FEE SUMMARY: PermitFee: $ 125.25 Valuation: $ 5,700.00
State Surcharge Fee: $ 3.35
TOTAL FEE: $ 128.60
APPLICANT: Plymouth Roofing&Insulation OWNER: Steven&Ellen Polansky
17525 Cty Road 24 1900 Fox Ridge Rd
Plymouth,MN 55447 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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APPL A T E MITEE SIGNATURE [SSULD BY SIGNATURE
Copies: 1-File(SiQnitures Reauired). 1-Applicant, 1-Monthlv Reports, 1-Assessine, 1-Finance Page 1
E . r .
Total Fee: $ Date Received:
Entered By: Permit#:
CITY OF ORONO - BUILDING PERMIT APPLICATION
All information must be subnnitted in full before plan review will be started.
(please pri�zt all i�:fo�i�iation)
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THE APPLICANT IS: (circle orte) OWNER OR ONTRACTO
JOB SITE ADDRESS: ����/ �� � !��� �� ZIP: SS��S,�
Will this be a Pa ade of Homes, Remodelers Showcase Home or other Display Home?
❑ Yes � No If yes, a special eveizt peri�iit is reqztired with Police Depai-tmerit arad City
Council approval 60 days pf�ior to tJze evef�t. Nori permitted everits will not �
be allowed.
NAME OF OWNER: /'� �- � � rGC.G( � PHONE: (home) .S� � �-��,�
� (��vork)
MAILING ADDRESS: ��'/C/Ci -�—G� �1C�i,C � CITY: Cu � !�l�F' ZIP: 5535,�
�,
CONTRACTOR: � ti'L6L' �� G� :��.� PHONE: 7(p�- �7�- � 3 %' �
CONTACT PERSON: - /" • MOBILE/PAGER: f�- 7/ — �G, 7�
MAILING ADDRESS: C-� 2c{ �-� CITY: l �. ZIP: SSf��"
STATE LICENSE: # S�Sd�
ARCHITECT/ENGINEER: PHONE:
MAILING ADDRESS: CITY: ZIP:
NAME: REGISTRATION #
TYPE OF WORK: New Accessory Structure
Addition Move
Remodel/Alteration Land Alteration
PROPOSED WORK(describe i�z detai�� �� r'l�'E' � ,�,�s �s�r/.�/=�'/ ,7i'�� v�
fetinr� s �x��� .<:✓���,F// 6rn� /ce,���a-�,�ci ��r�r� .
STORIES: SQ. FEET OF EACH FLOOR:
NO. OF BEDROOMS: GARAGE STALLS: ATT. DET.
ESTIMATED CONSTRUCTION VALUATION (excluding land): $ ���-r/,�U
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: � 1 DATE: ��—��I �
. .� . t
Sec.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 se[Corth in this section.
Subd.2. Information required to be given individual. An individual asked to supply private or confidential data concerning himself 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)
�vhether he may refuse or is legally required to supply the requested data;(c)any kno�vn consequence arising from his supplying or reCusing 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 o(ticer.
The commissioner ot revenue mav place the notice required under this subdivision in the individual income tax or nronertv tax re[und
instructions instead of on those forms.
Subd.3. Access to data b,y 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 further request,an individual who is the subject of
stored private or public data on individuals shall be shown the data without an��charge to him and,if he desires,shall be in[ormed of the content and
mcaning of that data. After an individual has been shown the private data and informed of its meaning,the data necd not be disclosed 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 of the private or public data upon request by the individual subject of the data. The responsible authority may
require the requesting person to pay the actual costs of making,certifying,and compiling the copies.
Thc 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 Saturdays,Sundays and legal holida,ys,if immediate compliance is not possible. If he cannot comply with thc request within
that time,he shall so inform the individual,and may have an additional five days fvithin which to comply tvith the request,excluding Saturdays,Sundays
and legal holidays.
Subd.4. Procedure when datn is not accurate or complete. An individual may contest the accuracy or completeness of public or private data
concerning himsclf. To exercise this right,an individual shall notify in�vriting the responsible authorit}'describing the nature of the disagreement. The
responsible authority shall rvithin 30 days either: (a)correct the data found to be inaccurate or incompletc 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 correct. Data in
dispute shall be disclosed only if the individual's statement of disagreement is included with the disclosed data.
Thc determination of thc responsiblc authority ma,y be appcalcd pursuant to thc provisions o(the adminish•ative 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 ma}�be shared with other local,state or federal agencies to the extent necessary to process
the permit or ticense.
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 above.
Signature