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Home My WebLink Aboutbldg permit application/not doing per builder Total Fee: $� � � �� ,u� ,,' Date Received: �-�-�-s Entered By: r.-� �, � �1 Permit#: 1�08� � �� CITY OF ORONO - BUILDIN� PERMIT APPLICATION All information must be submitted in full before plan review will be started. (please prirtt all infor•ntation) THE APPLICANT IS: (circle orae) OWNER O CONTRACTOR JOB SITE ADDRESS: � � � N o H--{-� ��-w� ��.�V �e. ZIP: -3 - �S Wil� this be a Parade of Homes, Remodelers Showcase Home or other Display Ho e � Yes ❑ No If yes, a special event perniit is required witla Police Depa t»z zt City Coacncil approval 60 days prior to the t. �z- e ai � events will not be allowed. NAME OF OWNER: �L Lc.r,c� �.�. �L��. e,�S PHONE: o e) �1 a..-��' 3� a l l 7 , ork) MAILINGADDRESS: �'` �`� ��ew'� ��--� �� ITY: c`e��ru��i�ZIP: S�-3 `i CONTRACTOR: �'e e �..o�n. w�.o.. \ �t e�s PHONE: �S � - `�1 �'/3 � d'aa �� CONTACT PERSON: ��v� O ILE AGER• ��a- g�I - oS c� � MAILING ADDRESS:Gl�� S ��. � ��e. ITY:�c�e�. ��'u��.�:�IP: S� 3�( 7 STATE LICENSE: # � 1 b(. XPIRATION DATE: 3 ' 3 / - v � �`� � ARCHITECT/ENGINEER: PHONE: MAILING ADDRESS: CITY: Z � NAME: REGISTRATION# TYPE OF WORK: New �_ Addition Accessory Structure Move Home Remodel/Alteration PROPOSED WORK(describe in detail): N-e w 5��`e `t'c�.w`��,�, � e s��e k�iq, � STORIES: �_ SQ.FEET OF EACH FLOOR: � ��.� o NO. OF BEDROOMS: �_ GARAGE STALLS: ATTACHED_� DETACHED_ ESTIMATED CONSTRUCTION VALUATION(excluding land): $__�� , o � O 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 " not to start without a permit;and that the work will be in accordance with the approved plan. APPLICANT'S SIGNATURE: � DATE: �— 3�� -S 9 5ec.13.04 RIGHTS OF SUBJECTS OF DATA - Subd.1. Type of dara. The rights of individual oa whom the datn is stored or to be stored shall be as set forth in this section. , Subd.2. Information required W be given individual. An individual asked to supply private or confidential data conceming himself shall be informed of: (a)the purpose and intended use of the requested data within the collectiog state agency,polidcal subdivision,or stauwide system;(b) whether he may refuse or is legally required to supply the requested data;(c)any known consequence arising from his supplying or refusing to supply private or confidential data;and(d)the idenaty of other persons or entities authorized by state or federal law to receive the data. This requirement shaU not apply when an individual is asked W supply investigative data,pursuant to secdon 13.82,subdivision 5,to a law enforcement officer. The commissioner of revenue mav nlace the nodce reauired under this subdivision in the individual income tax or orooertv tax refund instructions instead of on those forms. Subd.3. Access to data by individual. Upon request to�responsible authoriry,an individual shall be informed whether he is the subject of stored data on individuals,and whether it is classified as public,private or confidenrial. Upon his further request,an individual who is the subject of stored private or public dam on i�dividuats shaU be shown the dam without any chazge Co him and,if he desires,shail be informed of the content and meaning of that data. After an individual has been shown the privatc data and info�med of its meaning,the data need aot be disclosed to him for six moaths thereafter unless a dispute or acdon pursuant to this section is pending or additional data on the individual has been coUected or created. The responsible authority shalt provide rnpies of the private or public data upon requat by the individual subject of the data.The responsibie authoriry may rcquire the requesting person W pay the actual costs of making,certifying,and compiling the copies. The mponsible authoriry shall wmply immediately,iP possible,with any request made pursusint to this subdivision,or within five days of the date of the request,excluding Saturdays,Sundays and lega]holidays,if immediate compliance is not possibie. If he cannot comply with the request within that dme,he shall so inform the individual,and may have an addi6onal five duys within which to comply with the request,excluding Saturdays, Sundays and legal holidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or completeness of public or private data conceming himse[f. To exercise this right,an individual shall notlfy in writing the responsible authority describing the nature of the disagceement The responsible authority shall within 30 days either: (a)coaect the data found to be inaccurate or incompteu and atumpt to notify past recipients of inaccucate or incomplete data,including recipients named by the individual;or(b)notify the individual that he believes the data W be cartect Data in dispute shall be disclosed only if the iadividua('s statement of disagreement is included with the disclosed data. The determination of the responsible authority may be appealed pursuant to the provisions of the udministradve 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 aze 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 may be shared wi[h other local, state or federal agencies to the extent necessary to process the permit or license. 4. If your requested permit or license requires Council action to approve,some information rnay 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. S�"c �eti Uc�..^� s �c, � First Middle Last. �1"�� \ ��S�h �lac� Address , ��e�,. �,�a��.a `c�� S.s3`i7 9.S1 -9Y3 -8d-a � City State ZIp Phone I un nd y 'g ts as stated above. Signature 10 . . CHECK OFF LIST FOR ISSUANCE OF PERt1�IITS FOR OFFICE USE ONL Y � ADDRESS OR LEGAL: 7�10 N o��"� A2wi A� PID: DESCRIPTIONOF YVO.RK: NEI�J � -��5 ZOtYItVG RE ~ DATE APPROVED: �_�� s -_' -- -VIE YY B I`:-----�------ ------------- � , B UILDING RE VIE W B Y: Dr�TE APPR�6'ED: � ------------------------------- ------- FEES TO BE CHARGED: hfisc. Fees Calccclated By: PER1btIT Yes .� No PLAN REVIE6V Yes �/ No SEWER GOtViVECTIO�V STATE SURCHARGE Yes � tVo tiT/ATER GO�Vt�IECTIOIV � ItVVESTIGATlON FEE Yes �Vo � PARK FEE SAC ,Yes No _/ SITE INSPECTIOtV Ntunber of SAC_U�iits-�'�M�OFA��9 F^��"� (�¢�' OTHER (specify) _______-------- ----- --- L=�'2'r _=�Z]�---��=-'-�--�s------------------------------ Z'O�VIIYG CHECh'LIST Zonirtg Dish•ict: Post O �ce: Sclxaal DisA•ict: _.. Fire Depnrtrner�t: ff Lat.�Lt•ea: Sq.ft. �S �1�c"� Acres •8� GVidtft Depth Sccrvey Subtriitted; Yes X No Date af Sc�rvey: 3-1�'0� Proposed Set6nclu: �.� �re�nt(Gah.e): �05' Rig/�t Side: � �4atr(Sn•eet); i�3.s Geft Side: 3b•`1 Adjncent Structures: Wetlanc{: — Building Height: Def. Ffgt. 28�5 Peak Kgt. 3b•5 8J � Lot Coverage:� . Gracting: Staff App►'oval Dccte: Bv:; Counetl Approvc�l Dc�te: "— Septic: StaffApprouc�l Date: N�� BY� Zoni�:g Fife: # - Resolutio�s: # � Resoli�tion Dnte: � Sltorelanc{Dish�ict: v,r s Avg.Setback: O\ Bluff Setback: N�l4 . Lot Coverage: �% � Esisting Propased Har•dco�er•: 0-75' �S —— 75-250` . 3H•9 Z3'� , ZSO-S00' 3� Zg��-- 500-!000` Kar•dcover Variance Requireci: Yes No„�;_ Date of Cocincil Approval: .REMARKS(in:hoccse): . 31 ' , - � B UILDI�VG.RE YXEYt�CHECh'LIST UBC: _ . (Z•3 � COrYSTRUCTtO►Y TYPE: V N � Sq Footage .�Per•Sg Ft,; Basenieitt � _ Lst Flaor .r = ?nd Floor s = Gm•c J e c x = TOT�tL Estimated Caistrctctiait Vafi�e: ,� $�O�pp'p o�. Inspections Required: �F�ork R�quiriu;Separate Pe�vnits: Site _Z( Plumbing � Fire Hardcover Reinova! a Ntechnnicc�l �Yater Connecrian _�footing Septic _ � Setiver Conrcection _�t franlin� r Firep(ace _�t Law��lrrigatiai �_lrisitlatiat � (r�lnsonrl.) Odiel� � 6Ya1f BoRrd o� (h�Ifg.) _�c GVell(State Permit) _�Final Gradi,tg/Fiilin„ _�Elecmica!(Sta�e Per»iit) Other . ' RE�tiIARl'iS(,(N HO USE): � RE t?E tY'B Y OTHERS: DATE: �lccess: Existinu �VeH� t(ccess Approvrel: Date By: 1tEM�Rh'S(TO BE NOTED ONPE.Rt1�lIT): 32