HomeMy WebLinkAbout1999-011666 - land alteration ,� PERMIT
. CITY OF ORONO PERMIT TYPE:
2750 Kelley Parkway- P.O. Box 66 Permit Number: -- - ��--t ''v��;-`
Crystal Bay, Minnesota 55323 �_+'._ i����i�=
(612)473-7357 Date Issued: !F , �,�-:`i:�,T:
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SITE ADDRESS:
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DESCRIPTION:
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REMARKS:
FEE SUMMARY:
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CONTRACTOR: — ��°F°# i�=�-�?'� — OWNER:
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APPLICANT/PERMITEE SIGNAT E ISSUED BY:SIGNATURE ��
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'-,.i'otal Fee: $ Date Received: ��Q�� S _
Entered By: � Permit#: /���Co
CITY OF ORONO - BUII.DING PERMIT APPLICATION �
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All informa�ion must be submitted in full before plan re�iew �•ill be started. . �
(please print all information) .
THE APPLICANT IS: (circle one) O�YNER OR(CONTRACTOR
JOB SITE A.DDRESS: � t � - �c;r�c, �--,, f 1.�. C -� c_ ZIP: `��� �. f ��� �
NAME OF 4��'ER: `.� �- �� ; r �,_�_i� r PHONE: (home)
(work) �
I1�L�II.I�i tG ADDF.ESS: '-,�,��:-, ... � �_ c c���� CTTY: ZIP:
CO�CTOR: �, j - �- �� ' e �� ``- `MOBILE/PAG R. +/ ,� , )��c � "_. . r �:. '_
CONT'A.CTPERSON: "�' � �c.�.� �,r� " �' � --
� r� ac
�.�+ .�l��T���S.S: � �z � � ����> ��• f�. ^ � �- _CI�: �_� �C- �C�, r ( 7+�: - 7,
STATE LICE�TSE: # -- - �
ARCHITECT/ENGItii TEER: ., f. PHO�TE: �
�Itii'G ADDRESS: CTI'Y: ZIP:
NAME: REGISTRATION#
TYPE OF tiVORK: New Addition Accessory Structure
Move Remodel/Alteration Land Alteration ��
PROPOSED'4VORK(describe in detai�: �-_�� `�--�-�� - r. � - �-1 ' `�-�� ' �s'��=
i, � z" � \ ��- -�i� �• � � 1 -�� � r4 ` �. � � � .�.. ��,` �-�' r^�.>�<'.�
STORIES: SQ.FEET OF EACH FLOOR:
�'O. OF BEDROOMS: GARAGE STALLS: ATT. DET. �
ESTIi�iATED CONSTRUCTION VALUATION (excludi.ng land): $ /V (� �
I hereby apply for a buildina 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 Build�n� Code; that I understand this is not a permit and work is not to start without a
permit; and th�t the work will be in accordance with the approved plan.
APPLICAi�'T'S SIGI�TATURE: '1 � : �.� DA'I'E: � ��a `���
. �
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NOTE! Parade p,�Homes events require separate p�rmit approval by Police Department and
� City Couneil 60 days prior to tke event. Non permitted events will not be allowed.
Sec.13.04 RIGF3'TS OF SUBJECTS OF DATA '
Subd. 1. Tppe of daca. The righct of iadividual an whom the data is swred or ro be srncad shall be as set focch ia this secrioa
Subd.2. InLormation reqirirrd to be given indfv�dual. An individual asked to supply private or eonfideadal daa eoncerniag himself shaIl
be iaform:d o,`: (a)the purpose aad iatended use of the reqvutLd dam wichia the ealIecang Ytam ageary�poliacal subdivision,or scamwide rysc�m;
(b)whe�e,-he:..ay rFuse or is_legally requi-:d to suppty.the rquesud data:(c)any latown caastquence arising ftvm his supplyiag or refusing to suppiy
privac�or con:;Cer.�al daca;and(d)the idendry of ocher petsoas or enrides auc�orized by s�[e or fedaral taw to reteive�a.a.:j. This r_quirc�ea�s�all
not apply when an ir:dividual is 2sked to suppiy invesdgarive daa,pursuanc ro secdoa 13.82,subdivision 5. w a law e.zfoccemeat ofncer. . �
'L�e ce:-timissioner of revenu� mav olace the nodce r_�uir_d under this subdivision in the individual income taz or orooertv ez tefund
instrucdons instc=d of on chose forms.
Subd.3: Access to data by indiridu.ai. Upon requesc to a respansible auchodry,an individuaI shall be informed whather he is the subject
of star:d dan on individu�ls,aad wheeher i[is etau�-_d as public,private or conF.denaal. Upoa his furcher requesc,aa iedividual who is the subjecc
o!stored priva;e ar public dara on individuals shall be shovm ehe daa wi�hout any charge to him and;if he desiru,shall be infocmed of[he concenc
and meaning of diat data. Afcer an individual has been shown�he privare dae and iaformed o[ic�meaaing,[he dara need not be d'uclosed to him for
six moncfu chereafter unless a dispute or acdon purruanc co ehis secdon is pending ac addidoaal daa on the individual bas been coliecc:d or erea`d.
Tae cesponsibie auchociry shali�provide copies of che priva�or pubiic daca upon�equesc by the iadividual subjecc of che dam. The responsible auchoriry
may requir_ the r_qu:sdng person to pay ctie acncal coses ai making,eecdfying,and compiling the eopies.
The responsibla auchoriry shall eompiy immediately,if possible,wich any request made pursuanc co this subdivisian,or wichin five days of
the da�of�he teques4 ezcluding Sacurdays,Sundays and lega.l hotidays,if immediace compliance is not possible. If he eanaot eomply wi[h the requesc
wichin that dme,he shali so inform che individuaI,and may have an addiaona!five days within which to comply wich ehe raquest,ezciuding Sacurdays,
Sundays and legal holidays. .
Subd.4. Procedure whea data is nat accurate or eomplete. An iadividual may eont�st the accurecy or compleceness of public or privace
dara conceming tiunself. To exercise chis right,an individual shaIl aoafy in wridng che responsible auchoriry describing the nature oF the disagreemeac
The responsible authoriry shall wichin 30 days eicher; (a)corrocc the data found co be inaccurat�or incompiem and aa:mpc to norify past recipients of
inaccurace or incomplece data,including recipiencs named by the individu3I:or(b)naaEy che individual thac he believes the daca to be correct Dati
in dispuce shaIl be disclosed only if the individual's statemenc of disagreement is included wictt the disclosed data.
The dececminadon of the responsible auchoriry may be appealed pursuanc to the provisions of cha admicusQarive procedure act reladng co
contesud eases. •
DATA PRIVACY ADYISORY
In accordance with M.S. 13.04, Subd.2, "Rights of subjects of data", we would like to inform you that your requesc
for a pemut or Iicense from the Ciry of Orono or any of its departments may require you to furnish certain private or
confidential information.
You are no[ified that:
I. The information you furnish will be used to decermine your qualification for the permi[or license requested.
2. You may refuse to supply data, but refusal may require that the Ciry deny the permit or license.
3. The information may be shared with ocher local,state or federal a�encies to the et�ent necessary to process
the permit or license.
4. If your requested permit or license requires Council action to approve, some information may become
public, .
5. You have certain ri�hts 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 permic.
Firsc �fiddlc Lasc
Addreu
Ciry Sace Zip Ptioae
I understand my rights as stated above.
_�,�. � �
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Signamre
.
. � CHECK OFF LIST FOR ISSUANCE OF PERMITS
FOR OFFICE USE ONLY
ADDRESS OR LEGAL: 1 l��t 0 ,�,L.�,ur�� /�v�
PID:
DESCRIPTION OF WORK: CoiZA�o�N�
ZOtiTti G REVIEW BY: �i UAo^�� -W-- DATE APPROVED: �•�?-4'Qg
BUII.DPi G REVIEW BY: DATE APPROVED; .
FEES TO BE CHARGED: �' ��'^'� Misc. Fees Calculated By:
PERNIIT Yes C No
PLAN REVIEW . Yes No SEWFR CONNEC"TION
STATE SURCHARGE Yes No WATFI2CONNECTION
INVESTIGATION FEE Yes No PARK FEE
SAC Yes No SITEINSPECTTON
Number of SAC�Units OTHER (specify)
ZONING CS�CK LIST Zoning Districr. �tiv .
Fire Department: Post Office: School District: �
Lot Area: Sq.ft. Acres � Width Depth
Survey Submitted: Yes No Date of Survey:
Proposed Setbacks:
Front(Laice): Right Side:
Rear(Street): Left Side:
Adjacent Structures: We and:
Building Height: Def. Hgt. Pe �Hgt.
Lot Coverage:
Grading: Staff Approval Date: Council Approval Date:
Septic: Staff Approval Date: B :
Zoning File: # . Resolution: # Resolution Date:
Shoreland District:
Avg. Setback: Bluff Setback: L.ot Coverage:
. Ezisting Proposed
Hazdcover: 0-75'
75-250'
250-500'
500-1000'
Hazdcover Variance Required: Yes No Date of Council Approval:
REI�ZARKS(in house):
7
. i�. , . . . � . � . �..' ' _ � �'
BUILDING REVIEW CHECK LIST
�C: �— � CONSTRUCTION TYPE: ,�"— '
Sq Footage $Per Sq Ftg � ' .
' Basement � _
lst Floor x _
2nd Floor x = , � �
Garage x =
z = �
�
TOTAL
i
Estimated Construction Value: $ �� i
Inspections Required: Work Requiring Separate Permits: j
Site Plumbing Fire
Hardcover Removal Mechanical � Water Connecdon
Footing ` Sepric Sewer Connection �
Fr�g Fireplace Lawn Irrigation
Insulation (Masonry) Other
Wall Boazd (Mfg.) Well(State Permit)
�F� Grading/Filling Electrical(State Permit)
Other ;
, �
REI�ZARKS(IN HOUSE):
------------------ ----- �
REV�tii�BY OT'�RS: DATE: �
Access: Existing New I
,
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Access Approval: Date gy; ;
RE1I�IARBS (TO BE NOTED ON PERMII�: �
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$ �
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