HomeMy WebLinkAbout2010-000382-permit voided . �.r�S �a �� -
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City of Orono
Building Permit Application
for New Structures or Additions
Mailing Address: Permit number: ����"'OD(J3
��O�Q CrysBtal Bay, MN 55323-0066 Date received: J��oS�//!�
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a �J� ;�, a�� Street Address:' Received by: .�. �.
�'�,c, '' y" �~ 2750 Kelley Parkway Plan review fee: /1� �}" /„?�
L9kESHOg'� Orono, MN 55356
Total Fee: /�/_/ �G,J
Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us f� �J
This application form must be completed in full and all required information must be submitted.
Incomplete applications will be returned. (Please print)
GENERAL INFORMATION: ��
Job Site Address: �Q �o,��, GqKE � , Q,�n10, /�
Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes g] No
lf 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 demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed.
CONTRACTOR/APPLICANT INFORMATION:
Name: A/OQ7Un( t�OM65
State License# D 5 I�L '�� Expiration Date: ;� 3 i�/�
Phone: 6i�-3�7 - 7 LG/ office 7G -�s/-FJ�oo cell �i.�-�G7(I
Mailing Address: yy/G T��'/t,'v!n !�� City:MEQ��/a ZIP: ���D
Contact Person: (��}�� p(t,-�,�f Applicant is: Contractor / Homeowner (Circle One)
Email and/or Fax: 7G 3-�S��y'9`f7
PROPERTY OWNER INFORMATION:
Name: SO�RCE ConISTKUc'T��nl Cf�PITfF�--
Phone (day): '1(03-,SSj-U I D�
Address: 353s' PL�lMocl'Tt-� Bt�/O �Z/! City: PC..ylU0Jl1{ z�P: SsyyT
Email and/or Fax � ���n/ C�. Soc�P...C.� ^CC. CON` ��3•Ssi- �9 99
ARCHITECT/ ENGINEER INFORMATION:
Name:
Phone (day):
Address: City: ZIP:
Email and/or Fax:
PROJECT INFORMATION:
1.Type of Project 2. Proposed Use 3.Structure Type 4. Sewage Disposal&
Water Supply
New Construction j�Single Family with �Residence
Addition attached garage ❑ Garage/Accessory Bldg. ❑ Public Sewer
❑Accessory Building ❑ Single Family with ❑ Deck
❑ Relocation detached garage ❑ Office/Commercial ❑ Private Sewer
❑ Other: (specify) ❑ Multiple Family/Condo ❑Warehouse
❑ Public ❑ Storage ❑ Public Water
'*Any earth movement may require ❑ Commercial ❑ Other(specify)
MCWD review&permits. ❑ Industrial ❑ Private Well
Minnehaha Creek Watershed District(MCWD) ❑ Other: (SpeCify)
18202 Minnetonka Blvd
Deephaven,MN 55391
Phone: 952-471-0590
Fax: 952-471-0682
www.minnehahacreek.or
Estimated Construction Valuation (excluding land) $ /' 70.ODo.oa
Last Updated: 9/29/2009
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STRUCTURE INFORMATION:
1.Structure Dimensions 1.Structure Dimensions(continued) 2.Type of Construction
a. Length (ft.)= Number of bedrooms= ❑Wood/Frame
❑ Masonry
b.Width(ft.)= Number of garage stalls: ❑ Metal
Attached= ❑ Pole Bldg.
Areas in square feet Detached= ❑ ICF
❑ On-site Prefab
c. Basement= ❑ Off-site Prefab
d. 1 S`Story - ❑ Other(please specify):
e. 2"d Story=
f. '/z Story =
g. Total Area=
REQUIRED SUBMITTALS:
All of the information must be submitted in order for your application to be processed:
Not
Enclosed A licable
❑ ❑ Permit A plication
❑ ❑ Pro osed Buildin Plans
❑ ❑ MN State Ener Code Calculations and Mechanical Code Re uirements Form
❑ ❑ Surve meetin all re uirements
❑ ❑ Stormwater Pollution Prevention Plan
❑ ❑ Hardcover Calculation(s
❑ ❑ Se tic S stem Site Evaluation Re ort
❑ ❑ Access Permit
❑ ❑ Wetland Buffer Im rovement Pian
❑ ❑ En ineered Plans for Retainin Walls 4 feet or above
❑ ❑ Plan Review Fee
� ❑ Other w� �CL yN�LN I � p� �C' f) C_ WiK � � ��
APPLICANT ACKNOWLEDGEMENT:
. Agrees to provide all information required or requested by the Building Department;
• Agrees to pay the City of Orono for engineering consultant review costs in excess of$500;
. Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they
are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative
but to reject it until it is complete;
. Acknowledges the Escrow Agreement is completed and signed;
• Some or all of the information that you are asked to provide on this application is classified by State law as either private or
confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data.
Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and
intended use of this information is to annually update our records and records of other governmental agencies required by law.
If you refuse to supply the information,the application may not be issued.
ApplicanYs Signature: L �j"" Date: �`�G�/�
Last Updated: 9/29/2009
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