HomeMy WebLinkAbout2015-00361-VOIDED � I�b �r �e. � �l�����l
. �
City of Orono
Building Permit Application
r for New Structures or Additions
� Mailing Address: Permit number: —��
QA, PO Box 66
� `v� Crystal Bay, MN 55323-0066 Date received: - ��/�
Street Address:' Received by: !5—(JD
� ,� 2750 Kelley Parkway
y�' c,` Orono, MN 55356 Plan review fee: � ,
��kFs}.�0�� Main: 952-259-4600 Total Fee:
Fax: 952-249-4616 v�-���-c,.ci.uror��.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 INFORMATION: 3�
Job Site Address: o � �1.�v r,� �t� V
Will this be a Parade of Homes emo elers Showcase Home or other Display Home? ❑ Yes ❑ No
/f yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shutt/e 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: .V �' uv� ,5�.
State License# f�` � �- �.L ;?<' ;� ��."=�� �'�� Expiration Date: '3 i '�
Phone: (cell) �� �.-� �� ��L� (office)
Mailing Address: ,r- - _� v Cit : �i.,ti�-" o., '3ZIP: , �� f
Contact Person: � � -;v� � ✓1 Applicant is r$�facfo� / Homeowner (Circle One)
Email and/or Fax: 1<G/I iC�� ��Y1 k�_�'10'.E:�c.�• ."��:*<€��
�
PROPERTY OWNER INFORMATION:
Name: ��L� �j � v�
Phone (day): ��_ l Z' `� l 2- 06�j-�=�� 6l
Address: _��;}[� �: i,c>�� I���t VL., City: (�►'-U✓+ !� ZI P:Jc�%�- � '
Email and/or Fax
ARCHITECT/ENGINEER INFORMATION:
Name:
Phone (day):
Address: City: ZIP:
Email and/or Fax:
PROJECT INFORMATION: Description of project:
1.Type of Project 2. Proposed Use 3. Structure Type 4. Sewage Disposal &
Water Supply
�] New Construction �Single Family with [] Accessory Bldg./Garage
�.Qddition attached garage �.Deck ❑ Public Sewer
❑ Accessory Building ❑ Single Family with ❑ Office/Commercial
❑ Relocation detached garage ❑ Residence �.Private Sewer
❑ Other: (specify) ❑ Multiple Family/Condo ❑ Retaining Wall(s)
❑ Public 4-feet or greater ❑ Public Water
*`Any earth movement may require ❑ Commercial ❑ Storage
MCWD review 8�permits. ❑ Industrial ❑Warehouse � Private Well
Minnehaha Creek Watershed District(MCWD) ❑ Other: (speCify) ❑ Other(speCify)
15320 Minnetonka Blvd
Minnetonka, MN 55345
Phone: 952-471-0590
Fax: 952-471-0682
www.minnehahacreek.or
Estimated Construction Valuatio;� (excluding land) � �.5 U�Cl
Packet Last Updated: January 2015
Page 20
STRUCTURE INFORMATION: •
1. Structure Dimensions 1. Structure Dimensions (continued) 2. Type of Construction � '
a. Length (ft.)= � � Number of bedrooms= ��/�lood/Frame
� d/
b.Width(ft.)= � � Number of garage stalls: ❑ Masonry
Areas in square feet Attached = ❑ Metal
❑ Pole Bldg.
c. Basement= Detached= ❑ ICF �
d. 15t Story = ❑ On-site Prefab
e.2"d Story= ❑ Off-site Prefab
f. Y2 Story = ❑ Other(please specify):
g.Total Area=
REQUIRED SUBMITTALS:
All of the information must be submitted in order for your application to be processed:
Not
Enclosed A licable
❑ ❑ Buildin Permit Escrow A reement and Fees
❑ ❑ Plan Review Fee
❑ ❑ Com leted A lication Form
❑ ❑ Pro osed Buildin Plans–2 full size sets,to scale and 1 reduced 11 x 17 or 8'h x 11 set
❑ ❑ Minnesota State Ener Code Calculations and Mechanical Code Re uirements
❑ ❑ Surve –2 full size,to scale(meetin ALL surve re uirements
❑ ❑ Hardcover Calculations
❑ ❑ Se tic S stem Certification
❑ ❑ Minnehaha Creek Watershed District(MCWD)Permit or
Documentation form MCWD statin no ermit is re uired
❑ ❑ Landsca e Walls and/or Retainin Wall Plans
❑ ❑ Stormwater Pollution Prevention Plan SWPPP
❑ ❑ Access Permit
❑ ❑ Data Privac Adviso Form
APPLICANT/OWNER 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;
• Understands 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.
. Agrees that in the event that weather or other conditions prevent the completion of an as-built survey at the time the
Certificate of Occupancy is requested, a temporary Certificate of Occupancy may be issued upon receipt of a $10,000
escrow to ensure completion of the as-built survey and all site improvements.
ApplicanYs Signature: —� Date: 3 �y � �
Owner's Signature: Date:
Packet Last Updated: January 2015
Page 29