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C!TY OF ORONO PERMIT TYPE: _.
2750 Kelley Parkway • P.O. Box 815 Permit Number: ;=;i; :.;__i'.tuil
Orono, Minnesota 55356-0815 �-"�-'`'_'��=�
� . Date Issued: ; �:f.�;,.^.;,�:_;
(612) 473-7357 - -
SITE ADDRESS:
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APPLICANT/PERMITEE SIGNATURE � ISSUED BY:SIGNATURE � �
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CITY OF ORONO - BUILDING PERMIT APPLICATION
Total Fee: $ Date Received:
Date Approved:
Entered By: � �/
Permit�: '��`7`%
A�L INFORMATION MIIST BE SIIBMITT� IN FIILL BEFORE PLAN REVIEW WII,L B$ STARTED
(See Check-off List Enclosed)
THE APPLICANT IS: (circle one) 0 ER or CONTRACTOR
Jos sz� AnDxBss: % `� / �� /,1��-f; ;�-i / i ,-- � �' zzP: �� -j � I
(worx) �7 7 :J ��/
N�ME OF OWNER: � � � l.S (�,/ .. /J C- �, r, f� PHONE: (h ome) `i / S � 3 � �/
r�zixc �nnxEss: � l �b �-� (,-�' 1 ��� C� c'�" cz�: �"��1 Z�l �� zzP: S s .3 � I
cox�cTox: � 1`�� 1 r paorr$:
MAII�ING ADDRBSS: CITY: ZIP:
STATS LIGENSE: �
ARCHITECT/ENGSNEER: S�� � I � PHONE:
MAIZING ADDRBSS: CITY: ZIP:
rIAME: RBGISTRATION �
`�YPE OF WORR: New Addition Accessory Structure Move
Demo Remodel/Alteration� Renovate Land Alteration
PROPOSED WORR (describe in detail) : ZN S T/� � � /� 1` ��1 w /�i�r C�l C�,.J
/��G ' 1�� � � i� �� ��
;;TORIES: l- SQ. FEBT OF EACH FLOOR:
NO. OF BEDROOMS:�_ GAR1fGB ST�LLS: ATT.� DET.
ESTIMATED CONSTRIICTION VALIIATION (eacluding Iand) : $ S � v '� ��
i hereby apply for a building permit and 2 acknowledge that the information
sbove is complete and accurate; that the work will be in conformance with the
�rdinances 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
:nat the work wiI 1 be in accordance with the approved plan. ,
, � �
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PPLICANT'S SIGNATURE: '� ��-�' / ����� `J DATE: l� � �i n�
.
CITY of ORONO
Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices
•
� _ � e On the North Shore of Lake Minnetonka
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 wi3.1 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 Iicense.
3. The information may be shared with other �ocal , state or
federal. agencies to the extent necessary to process the permit or
license.
4. If your requested permit or Iicense requires Councii. action
to approve, some information may become public.
5. You have certain rights under M.S. 13.04 �o review pri�at�
data on yourself.
6. Your full name is required to process this applicatiaa or
permit.
�� u � � `� C, I < l� �=" � (, �' � �
First Middle Last
% � � 0 i� 1=� 1 fi�9 G � ,�� � -
Address
ui�v � ��� �� ���>�� .�s- � �l
Cit—y State Zip
�/ �- �� `� S- ,�/
Phone
I understand my rights as stated above.
. / �
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Signa ure
BUILDING&ZONI[YG—473-7357 • ADMINISTRATION&FINANCE—473-7358 • PUBLIC WORKS—473-7359
ASSESSING
�.04 RIGHTS OF SIIBJECTS OF DATA
Subdivision L Type of data- The rights of individuels on whom the data is
stored or to be stored shall be as set forth in this section.
Subd. 2. Information required t° be g��� u'���1" An.individual asked to
� supply private or confidential agtg � uested d tamw hin the collecti g state gency,
purpose and intended use of the req tem; (b) whether he may refuse or is legally
political subdivision, or statewide sys
required to supply the requested date; (c) any known consequence arising from his
supplying or refusing to supply private or confidentiel date; and (d) the identity of
other persons or entities authorized by state or federal law to receive the data. This_
1 when an individusl is esked to supply investigative date,
requirement shall not app y
pursuant to section 13.82, subdivision 5, to a law enforcement officer.
The commissioner of revenue og rolertv taX re�und instructe ns�i steadhos
subdivision in the individual income tax
on those orms. . - — - -
Subd. 3.
Access t� �ata bY in�n�• UPon request to a responsible �
authority, an individuel shall be informed whether h��gteeor confidential.e Upon his
individuels, and v�►hether it is classified as public, p ublic data on
further request, an individuel who is the subject of Se to himrlande if he desires, shall
individuels shall be shown the date witho ofan�y ��ta. After an individual hes been
�e informed of the content end meaning the data need not be �isclosed to
shown the private data and informed of its meaning,
him for six months thereafter unless a ,��P�e h� b en collected or crreatedtioT��s
, pending or additional data on the indivi ublic data upon request by
responsible authority shall provide copies of the private or p require the
the individual sub��ect oftne actual.�osts of mak ng,i cert fyingy and compiling the
requesting person P8Y -
copies. immediately, if possible, with any request
The responsible authority shall comply
made pursuant to this subdivision, or �th lida e,�f Simmediateg compliance eisu n�t
excluding Saturdays, Sundays and leg YS
possible. If he cannot comply with the re9five �thin�i��ntW�ch toh omplynw�h the
individual, and may have en additional Y5
request, excluding Saturdays, Sundays and legel holidays.
Subd. 4. Procediu'e �►hen data is not accurate or complete. An individual may
contest the accuracy or completeness of public or private data concerning himself. To
exercise this right, an individusl shall notify in writing the responsible authority
describing the nature of the disagreementbeTnacciu�ate orin omplete and att pt to
days either: (a) correct the data found to
notify past recipients of inaccurate or incomp�t he believes�the datalto be correcty
the individual; or (b) notify the individual eement is
Data in dispute shall be disclosed only if the individual's statement of disagr
• included with the disclosed data. e�1ed pursu�t to the
" The determination of the responsible authority may be aPP
provisions of the administrative procedure act relating to contested cases.
DATE TIME
CI�Y OF ORONO CALLED W � �� y
INSPECTION NOTICE `��j� SCHEDULED � �// �I • -� d
PERMIT NO. � COMPLETED �( �
ADDRESS �� ` N� '
OWNER CONTR.
TELEPHONE NO. ''��� ������
� DESCRIPTION ��-���-'� /�GC��'
W 01 FOOTING 11 MECHANICAL RI 16 WELLTEST PUMP
�
Q 02 FRAMING 11 MECHANICAL FINAL 18 EXCAVIGRADING/FILLING
� 03 INSULATION 24/25 WOOD BURNER/FIREPLACE 19 LAKESHOREIWETLANDS
O
Z 04 WALL BD. 12 WATER HOOK-UP 34 TREE REMOVAL
Q FINAL 13 METER SETITURN ON 17 SITE INSPECTION
� 07 DEMO—SITE 14 SEWER HOOK-UP O6 PROGRESS
J 07 DEMO—FINAL 27 SEPTIC MAINT. 21 COMPLAINT
Q
= 09 PLUMBING RI 15 SEPTIC INSTALL. 22 FOLLOW-UP
J 10 PLUMBING FINAL 23 SEPTIC FINAL
� OWNERICONTRACTOR TO MEET YOU:_YES_NO
� COMMENTS:
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W ORKSATISFACTORY:PROCEED ROJECTCOMPLETE
� 7 CORRECT WORK 8 PROCEED �; ISSUE CERTIFICATE OF OCCUPANCY
W
� ; CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
� BEFORECOVERING
V PERMANENT
f�CORRECT UNSAFE CONDITION WITHIN HOURS. , pHOTO TAKEN
INSPECTOR WILL RETURN
CITATION ISSUED
�;STOP ORDER POSTED.CALL INSPECTOR
G INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call for the next i spection 24 hours in advance.473-7357
OwnerlContr c on si : _
Inspector. �
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