HomeMy WebLinkAbout2016-00040 - adv plan review CITY OF ORONO * 2 0 1 6 - 0 0 0 4 0 *
2750 KELLEY PARKWAY DATE ISSUED: OUi4/2016
�� ORONO, MN 55356-
(952) 249-4600 FAX: (952) 249-4616
ADDRESS : 3640 JACOBS MILL RD
PIN : 32-118-23-24-0010
LEGAL DESC : JACOBS MILL
: LOT 004 BLOCK 001
PERMIT TYPE : ADVANCED PLAN REVIEW
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : ADVANCED PLAN REVIEW
VALUATION : $ 110,000.00
NOTE: PLEASE FILL IN THE FOLLOWING:
VALUATION OF PERMIT:$ 110,000.00
TYPE OF PERMIT THIS PAYMENT IS FOR: BASEMENT FINISH
PERMIT#THIS PRE-PAYMENT IS TIED TO:2016-00041
APPLICANT ADVANCED PLAN REVIEW 762.40
WOODDALE BUILDERS INC. TOTAL 762.40
61 17 BLUE CR DR Payment(s)
CHECK 84454 762.40
MINNETONKA,MN 55343-
(952)345-0543
Minnesota State License#: BUIL-BC002926
OWNER
HOFFMAN,KEITH&MARY
3640 JACOBS MILL RD
LONG LAKE, MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be performed according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances governing this rype of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be � .
revoked at any time for due cause. ' _'� ;�
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Applicant�ermitee Signature Date Issued By Signature Date '
City of Orono
E�uilding Permit Application for Maintenance / Replacement / Remodel
(i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION)
�O� Mailing Address: Permit number: v�a� - ��
O PO Box 66
Crystal Bay, MN 55323-0066 Date received: � ��-3 ��
Street Address: Received by:
y� � 2750 Kelley Parkway : ;;{�;: �O� ;�,
`�'�ESHD��G Orono, MN 55356 ���� �
Total Fee: a ���r �
Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us
This application form must be completed in full and all required information must be submitted.
Incomplete applications will be returned. (Please print)
GENERAL INFORMATIO : .
Job Site Address: pj C �b ,s �t �,� dU1��
Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? Yes o
If 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:
State License# o(� Expiration Date:
Lead Certification Number: NOw� Expiration Date: N�ry� �
(for work on homes fhat were consfructed prior to 1978
Phone: (cell) . ` • (office) � s�s • O,S �/,�
Mailing Address: � City: � M,�'r�,,,,�M ZIP:,��
Contact Person: � • Wj t,'�'�,y�,s Applicant is: ontractor Homeowner (Circle One)
Email and/or Fax: b1' E 1�( � � W 00� Y1�,L�. B V i �.�E � C t�NM
PROPERTY OWNER INFORMATION:
Name: �� T N t M 1/L � � 1�� Iq N`�
Phone (day): . • �
Address: �l� � City: ZIP:
Emailand/orFax: KE�TMMof� �►�w i .s''�,S'�e � M�1i �. � CGwr►
PROJECT INFORMATION: Overall project description: �. l " F�w�6 N . ��� C��S T 0 D� Y�
Type of Project: Any earth movement may also require
❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review 8�permits:
❑ Re-roof, asphalt ❑ Repair ❑ Storm Damage Minnehaha Creek Watershed District(MCWD)
18202 Minnetonka Blvd
❑ Re-roof, cedar ❑ Restoration ❑Water Damage Deephaven, MN 55391
❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify) Phone: 952-471-0590
Fax: 952-471-0682
❑Window(s) ��� ��w+i�N � www.minnehahacreek.orp
Estimated Construction Valuation of Project (excluding land) $ u b0 D 0
APPLICANT ACKNOWLEDGEMENT: �
• Agrees to provide all information required or requested by the Building Department;
• Certifies that the information supplied is true and correct to the best of his/her knowledge. The ap icant recognizes that they are
solely responsible for submitting a complete application being aware that upon failure to do so, t staff has no alternative but to
reject it until it is complete;
• 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 an u date our records and records of other governmental agencies required by law. If
ou refuse to su I th ' on,the a lication ot be issued.
ApplicanYs Signature. . ___ - Date: � Z
Owner's Signature: Date:
Last Updated:January 2015