HomeMy WebLinkAbout2018-00317 - bldg permit appl y
g 7 9, g',U
City of Orono 2
Building Permit Application
for New Structures or Additions e 5Crow '��
Mailing Address: Permit number:D`Y ,;,erg—0d 3 i 7
A, PO Box 66 p
/� �`1ti\oro,
Crystal Bay, MN 55323-0066 Date received:
r 3-/Q-/p
14-
{ Street Address:' Received by:
( j 2750 Kelley Parkway Plan review fee: % . 302
�0 , Orono,MN 55356 g01?-.°63)4i
ke i/ Main: 952-249-4600
Total Fee:
Fax: 952-249-4616 www,ci.orono.rnn.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:
Job Site Address: 3 S SS- CRwy S+-A- P L .
Will this be a Parade of Homes, Remodelers Show ase Home or other Display Home? ❑ Yes kiNo
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: E \(Ae .
State License# C. 6. C)9 Z 3 Expiration Date: 2-,9 'A
.
Phone: (cell) 6 2.-7 c.) v 3 -1kl (office)
Mailing Address: 3c" N> TKA N icAtn, �( . t 1l Q City: M ,ti��QLZIP: 5 C 4 ti/
Contact Person: Q(+r'q� Z(-1 'k Applicant is: / Homeowner (Circle One)
Email and/or Fax: C 0N-A- %c-k- Ca)L LkB \VC\-LC ME , C
PROPERTY OWNER INFORMATION:
Name: <--1'3 "\Q. •
Phone(day): k 2-70 '
Address: 5 t,' V\ t'1 . k(ci City:PYPA,DtJt ZIP: S S 111--t(
Email and/or Fax C(;)144 A i-k CAA 13e 1r1C\-1 7f a.. CO(`n
ARCHITECT/ENGINEE INFORMATI N:
Name: -i--‘2N/G ORA H-i OCI ‘400 me c-3S ig /✓
Phone(day): 61'2 2� 5_2_____-12._
,.{ >L
Address: 3tQO Q �P kS t Pe�/I 0 i\\. 5 . City: ,. •\-. \,S, (4IP: - 41 2k
Email and/or Fax: S- 1- 2 Q;P+ -k-1 i1c\Ca, Cy's'N A l . Co r1
PROJECT INFORMATION: Description of project:
1.Type of Project 2.Proposed Use 3.Structure Type 4.Sewage Disposal&
Water Supply
New Construction L Single Family with 0 Accessory Bldg./Garage
Addition attached garage ❑ Deck Public Sewer
❑Accessory Building LI Single Family with Office/Commercial
❑ Relocation detached garage Residence ❑Private Sewer
❑Other:(specify) ❑Multiple Family/Condo Retaining Wall(s)
❑Public 4-feet or greater yr Public Water
**Any earth movement may require ❑Commercial ❑Storage
MCWD review&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.or4
Estimated Construction Valuation (excluding land) $ 2.2 5 .
00
Packet Last Updated: August 2015
Page 21
STRUCTURE INFORMATION:
1.Structure Dimensions 1.Structure Dimensions(continued) 2.Type of Construction x-,
a. Length(ft.)= `, w Number of bedrooms= 11�CGV,0(44 GJr
Wo.• /Frame/ C�
b.Width(ft.)= Number of garage stalls: I\ M. onry COI d� �d rte--/� i
Areas in square feet Attached= �. ❑ -tal
I=1 -ole
ole Bldg.
c. Basement= ii U Detached= I F
d. 15'Story = l J • -site Prefab
e. 2nd Story= 5=S-.2
❑O'-site Prefab
f. 1/2 Story = I ❑Ot -r(please specify):
g.Total Area= TJ
REQUIRED SUBMITTALS:
All of the information must be submitted in order for your application to be processed:
Not
Enclosed Applicable
❑ ❑ Building Permit Escrow Agreement and Fees
❑ ❑ Plan Review Fee
❑ ❑ Completed Application Form
❑
0 Proposed Building Plans—2 full size sets,to scale and 1 reduced 11 x 17 or 8'/2 x 11 set
❑ ❑ Minnesota State Energy Code Calculations and Mechanical Code Requirements
❑ ❑ Survey—2 full size,to scale(meeting ALL survey requirements)
❑ ❑ Hardcover Calculations
❑ ❑ Septic System Certification
❑ ❑ Minnehaha Creek Watershed District(MCWD)Permit or
Documentation from MCWD stating no permit is required
❑ ❑ Landscape Walls and/or Retaining Wall Plans
❑ ❑ Stormwater Pollution Prevention Plan(SWPPP)
❑ ❑ Access Permit
❑ ❑ Data Privacy Advisory 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.
Applicant's Signature: i ��-"'� Date: 0 3 ( \ 1
�9 ' -
Owner's Signature: P:>. � 03 (1 C _ Date: I
Packet Last Updated: August 2015
Page 22
Builder Acknowledgement Form
Permit #2018-00317 / 3555 Crystal Place
Builder Representative Name: 1c--(A)-iv lC--
Permit Conditions: Initials
**NOTE CHANGE** Before scheduling an exterior insulation and/or drain tile inspection, a
foundation as-built survey must be submitted and approved by the City or a Stop Work order 2
will be issued.
Schedule a minimum of one hour for the framing inspection.
Erosion control mechanisms must be installed and inspected by the City prior to any land
disturbing activities. The contractor must provide a minimum of a 24 hour notice prior to
inspection.
Erosion control shall be installed and maintained throughout the entire project and must
remain until vegetation has been established. P_--
Street Cleaning—Streets shall be cleaned and swept within 24 hours whenever tracking of
sediments or soils occurs and before the site is left idle for weekends and holidays.
Driveway requires paving from roadway for 30 feet in order to reduce driveway runoff (�
depositing soil and debris upon the roadway. Orono Municipal Code Section 18-136(f).
Separates utility permits are required for the sewer and water connections.
The grading plan/survey does not depict the public utilities. The sanitary sewer service appears
to be approximately located under the proposed driveway. See sewer as-built excerpt below.
The water stub is located in vicinity of the culvert.
N
50
50
1'144 OD-
4.
D®
ore
Prior to the issuance of a Certificate of Occupancy an as-built survey and hardcover calculations 7---7
must be submitted and approved.
In the event of winter or other extended unfavorable weather conditions(which prevent the
completion of the exterior improvements and/or as-built survey) a Temporary Certificate of
Occupancy(TCO) may be necessary. A TCO requires a $10,000 escrow. t—
w:\street files\crystal place\3555\builder acknowledgement form 2018-00317.docx
Builder Acknowledgement Form
Permit #2018-00317 / 3555 Crystal Place
Builder Representative Name: /4 LA
Permit Conditions: Initials
Advisory Comments
Any changes to the exterior/landscaping improvements, i.e. patios, grading, sidewalks, retaining
walls, etc. not currently shown on the approved survey and landscaping plan will require a
separate Zoning Permit application to be submitted and approved prior to the work 1--)
Z_.-..
commencing.
Any retaining walls that are over 4-feet in height or tiered walls not separated by twice of the
height of the lower wall require engineered plans and a building permit to be submitted and "?--
approved
approved prior to construction.
w:\street files\crystal place\3555\builder acknowledgement form 2018-00317.docx
PLAN REVIEW CHECKLIST FOR NEW STRUCTURES / ADDITIONS
Address: 5,,r' 5 l�/ ��'�... vd��X„ Permit No.: 215-- )7
Description of work: I v Vw Date Rec'd: 3' 1 • Lu
/ i "t.. f3v•1'f'�f�,-'e- l'1 Z1 -Ft 54-G. (AI it Blued)
Septic review by: �/ i--- vDate Approved:
Zoning review by: CY I C IA Date Approved: A . 11 . L 1
-4
Building review by: 04 e�� Date Approved: 3A07/0'% '4-1-.11 1
Grading review by: i {� alucutirn Date Approved:
Zoning District: L-'"' K-' Zoning File#:
Resolution? Yes Reso#: Reso Date: Signed: Yes No Resolutio tI
Zoning: Lot Area: it f tO SF/AC Width: Structural Coverage: lqo D SF 133
Survey Submitted: pKes D No Date of Survey: 3 5 .1 ' Revised date(?): _
Landscape plan submitted? D Yes Landscaper: A5 show ►1D N / None propose
Proposed Setbacks:
3D 1a lb
( e
Front j� Rear( et) ( N S W ) ( N c' E 10) Other Buildings Wetland
Si le
101 5 f ' 27 '
Building Height Analysis:
4Distance Between First Floor and r' qht" a
definition): � ' 23+J
First Floor Elevation (f,: t j (b) 64 3
Highest Existing ground1- 3 ,i (c) n5�/
whichever is lower: I i 11
Difference between (b) ano (d) j ,
DEFINED HEIGHT
*If h" acent ) Z7.3
*If highest existing adjacent grade is
Shoreland District MCW, shore Setback Bluff
Met?
es 0 No Permit Number: _ Yes 0 No N/A 0 Yes "o1‘
0 N/A-see attache, L6 I Setback:
Stormwater Quality Existing Proposed
Overlay District Tier Hardcover Hardcover Variance Required CUP Required
(circle one) (% and sf) (% and sf)
0 Yes No 0 Yes No
1 2 0 4 5 33 kt1.s f Type(s): Type(s):
1AtcM4ed 2-S90 Ao c1- Qv wie --.
Vc�lana
Updated: June 2017
z:\forms\plan review checklist 06-2017.docx
Fees to be Charged • YES NO
, Permf ,, a .� , _ x ,� t --:,-44,
Plan Review V
;State Surcharge eU'r' _
Investigation Fee l`./'
SAC-Number of SAC Units ,: ''.., '' K
Other(specify)
Square Footage $ per Square Footage
Basement f 2-8(e X 87,4LZ = $ f iZ-, 9ZZ., /
1st Floor /Z-8(e X /0 3-?Z-. = $ 133 le 41,1 Z.
2nd Floor / .-.V X 103 • ?z. = $ llel) / 7c-j. `!Z.
Garage 9-8 ct x 3 °fe 9-q-- = $ / �/z.8&., /(P
Estimated Construction Value: $ / 000
---
Orono Inspections Required Work Requiring Separate Permits
Footing ❑ Site Plumbing
0 Grading/Filling
Poured WallSilt Fence/Erosion Control Mechanical 0 Fire
Foundation Survey 0 Hardcover Removal ,Fireplace Water Connection
0 Framing 0 Other(specify) 0 Masonry Sewer Connection
.Waterproofing/Drain tile , Mfg. 0 Lawn Irrigation
❑ Foundation Waterproofing 0 Other(specify) 0 Landscaping
IF0raming
Septic
Insulation
As-Built Survey
Final
Lathe Required State Permits
❑ Other(specify)
0 Well )2(Electrical
REMARKS (in-house):
OFFICIAL REMARKS -TO BE NOTED ON PERMIT AND INITIALLED:
❑ See Builder Acknowledgement Form
O Prior to release of escrow money an as-built survey and hardcover calculations must be submitted and approved.
Updated: June 2017
z:\forms\plan review checklist 06-2017.docx
Christine Mattson
From: Adam Edwards
Sent: Wednesday, March 21, 2018 2:33 PM
To: Christine Mattson; Laura Oakden; Melanie Curtis;Jeremy Barnhart; Roger Peitso
Subject: 2018-00317/3555 Crystal Place
Planners, miscellaneous
Not sure who put this on in my inbox. I assume I was to review the grading plan which I did.
I stamped the grading plan approved with the following comments:
1. Perimeter sediment control measures must be installed by the contractor and inspected by the City prior to any
work, including demolition. Contractor must provide minimum 24 hour notice prior to inspection.
2. Special care will need to be exercised in creating the drainage pattern on the sides of the property to ensure
that run off is not directed onto the neighboring properties.
3. Street cleaning-Streets shall be cleaned and swept within 24 hours whenever tracking of sediments or soils
occurs and before the site is left idle for weekends and holidays.
4. Driveway requires paving from roadway for 30 ft. in order to reduce driveway drive way runoff depositing soil
and debris upon the roadway. Orono municipal code Sec 18-136 (f).
5. A separate utility permits will be required for the sewer and water disconnections prior to demolition and for
connections.
6. The grading plan survey does no depict the public utilities. The sanitary sewer service appears to be
approximately located under the proposed driveway. See sewer as built excerpt below. The water stub is
located in vicinity of the culvert.
mkt
.d _
50 . 50 50
40-
Q J 0J + tin.
[1:19
Adam
Adam T. Edwards, P.E.
Director of Public Works/City Engineer
City of Orono
(952)249-4661
aedwards@ci.orono.mn.us
1
Permit Application: Self-Checklist for Completeness
Please note, the applicant must initial in the boxes below to acknowledge the minimum
required information is included with the submittal. If not, the application will NOT be
accepted. Call 952.249.4620 to schedule a meeting with staff if you have questions on
application submittal requirements.
I. Completed Application
Plan Review Fee Paid
Signed Escrow Agreement & Escrow Payment
Building Plans (to scale) x2
Certificate of Survey (to scale) showing the proposed project &
meeting all requirements x2
Hardcover Calculations (if applicable)
I am aware that Orono will not issue a building permit without a
copy of MCWD permits (or documentation from the MCWD stating
the proposed project does not trigger their permitting
requirements). I will contact the MCWD at 952-471-0590
regarding this project.
Signed by: _
Address: 3 SSS C- -5-ift--1 -{ 1--
Permit
Permit #:
Packet Last Updated: August 2015
Page 2
City of Orono
oNo Hardcover Calculation Worksheet
:,,,,, i.: Property Address: s 5 s-- C° . -�� 1
f
/
``' Prepared by: Date: 0 1 ..., ((te)
(
Stormwater Quality Overlay District Tier: (Circle one) Tie ierat)
Tier 4 Tier 5
• Step 2: PROPOSED HARDCOVER
In the following table, identify all items of proposed hardcover on the property, keyed by letter to Certificate of Survey
(survey must accompany this form). Include all existing hardcover items that are intended to remain, as well as all
proposed hardcover items that will be added. Use as many lines as necessary to accurately depict proposed hardcover
status of the property. For Tier 1 properties, identify any features by letter which are split at the 75'setback line and
calculate hardcover square footage separately for each portion.
Key to Hardcover Item (Describe) Length x Width Total
Survey (Square Feet)
(Example) (Garage) (24'x 30) (720 S.F.)
A 0U,s(2- =>0 X :')f;,"7 CCS .'{6 S.F.
B S.F.
C S.F.
D p-e e- 39,:5 ylJ 75 !_(oci S.F.
E -12C)N-k- .S-1/4-.2S }�-VOO i`Z ?C - 2. S.F.
F Inc' Q e.-k S kdQ W'A�(G • S.F.
G nLve w>4y .7. ' X 0. . 8 0 S.F.
S.F.
I S.F.
J S.F.
K S.F.
L S.F.
M S.F.
N S.F.
O S.F.
P S.F.
Q S.F.
R S.F.
S S.F.
T S.F.
U S.F.
✓ S.F.
W S.F.
X S.F.
Y S.F.
Z S.F.
(1) Total Proposed Hardcover S.F.
Excludable Hardcover(See City Code Sec 78-1684):
S.F.
S.F.
S.F.
S.F.
S.F.
(2) Total Excludable Hardcover S.F.
(3) Net Proposed Hardcover [Subtract line(2)from line(1)] - S.F.
(4) Total Lot Area S.F.
Proposed Hardcover Percentage ((3)_(4)] 2 j 0,0
4 kqumei /576 - toI b of or I- wioN4 vaW1 evlc-.-
Packet Last Updated. January 2015 This is an information packet regarding Hardcover. Every effort has been made to
ensure the accuracy of the information contained herein;however,if any information is
not consistent with provisions of the City Code,the Code provisions will prevail.
Page 17
3� CJS 1 ct,
p,4 ,i - 221
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CJ�IV ID m L� of-otokubkIr
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American Land Title Association ALTA Settlement Statement-Borrower/Buyer
Adopted 05-01-2015
Executive Title
ALTA Universal ID:
3217L Galleria
Edina, MN 55435
File No./Escrow No. : SA18020108
Print Date&Time: February 23, 2018 10:16 am
Officer/Escrow Officer: Sara Anderson
Settlement Location : 3217L Galleria
Edina, MN 55435
Property Address: 3555 Crystal Place
Orono, MN 55391
Buyer: Cube, Inc.
Seller: Estate of Dean Young
3555 Crystal Place
Orono, MN 55391
Lender: Cash
Settlement Date: February 23, 2018
Disbursement Date: February 23, 2018
+ Aq m =moi t
u hul Descrfption 7i iG"P"�aii:�M�V��k+, itt m�! i i�n�
u t� i ; �i h � ��i �� v `hfl ate a at � A' t���
u i ill i� ung i ( r 1;1'lN4tg ,et � �C'.-.,r�e'dit-
p
Financial
Sale Price of Property 105,000.00
Deposit
3,000.00
Prorations/Adjustments
County Taxes 101.38
01/01/18 -02/23/18
Title Charges and Escrow/Settlement Charges
Buyer Closing Fee to Executive Title 195.00
Disbursement Fee to Executive Title 100.00
Search& Exam Fee to Executive Title 600.00
Owner's Title Insurance to Executive Title 367.50
Coverage: 105,000.00
Premium: 367.50
Commissions
BrokerAdmin Commission to Lakes Sotheby's International Realty 495.00
Government Recording and Transfer Charges
Copyright 2015 American Land Title Association File#SA18020108/17
All rights reserved Page 1 of 2 Printed on 02/23/18 at 10:16:08AM by sanderson
•� Description 1 7,1 - .��� .. -�,
itarig
41 4.' ,�€ Cry ,. b ^"' ' _ ei
Government Recording and Transfer Charges(continued)
Recording Fees to Henne?in County Recorder 4600
14'41 �.00 .deb . ttO Credit ?��'
Subtotals 106,803.50 3,101.38
Due from Buyer 103,702.12
Totals 106,803.50 106,803.50
Acknowledgement
Well have carefully reviewed the ALTA Settlement Statement and find it to be a true and accurate statement of all receipts
and disbursements made on my account or by me in this transaction and further certify that I have received a copy of the
ALTA Settlement Statement. We/I authorize Executive Title to cause the funds to be disbursed in accordance with this
statement.
Buyer
Cube, Inc.
BY: lt ��•v` ,.'
'man 2°uk
'reside,
de II 1
Sara An
Executive Closer
Copyright 2015 American Land Tide Association File#SA18020108/17
All rights reserved Page 2 of 2 Printed on 02/23/18 at 10:18:06AM by sanderson
(Top 3 inches reserved for recording data)
DEED OF SALE Minnesota Uniform Conveyancing Blanks
by Individual Personal Representativeen/_ to Business Entity Form 10.5.5(2013)
eCRV number: t 1(J I
DEED TAX DUE: $ ' ICJ DATE: Februry 22,2018
(month/day/year)
FOR VALUABLE CONSIDERATION,Sandra J.Swenson
(Insert name of each Personal Representative)
as Personal Representative of the Estate of Dean Youna
,Decedent, single® married EP at the time of death
(check applicable box)
(If"married'is checked,then attach a Consent of Spouse[Form 70.1,1])
("Grantor"),hereby conveys and quitclaims to Cube.Inc.
(Insert name of Grantee)
a corporation under the laws of Minnesota ("Grantee"),
real property in Hennepin County,Minnesota,legally described as follows:
Lots 6 and 7, Block 3,"Navarre Heights," Hennepin County Minnesota
Check here if all or part of the described real property is Registered(Torrens)❑
together with all hereditaments and appurtenances belonging thereto.
Check applicable box: Grantor
• The Seller certifies that the Seller does not know of any wells on
Q �
the described real property.
❑ A well disclosure certificate accompanies this document or has (signature of Personal Rep
been electronically filed.(If electronically filed,insert WDC Sandra J.Swenson
number: .)
❑ I am familiar with the property described in this instrument and (signature of Personal Representative)
I certify that the status and number of weQs on the described
real property have not changed since the last previously filed
well disclosure certificate.
Page 1 of 2
Page 2 of 2 Minnesota Uniform Conveyancing Blanks Form 10.5.5
State of Minnesota,County of Hennepin
This instrument was acknowledged before me on February 22,2018 ,by Sandra J. Swesnon
(month/day/year) (Insert name of each Personal Representative)
as Personal Representative of the Estate of Dean Young ,Decedent.
(Stamp) ...----
e'' MICHELLE R HUEBNER ( ofrroteda�afAter)
Title(and Rank):
, ) Notary Public-Minnesota
3 0r M'�61+00 Jen 31, My commission expires:
(month/day/year)
THIS INSTRUMENT WAS DRAFTED BY: TAX STATEMENTS FOR THE REAL PROPERTY DESCRIBED IN THIS
(Insert name and address) INSTRUMENT SHOULD BE SENT TO:
(Insert legal name and residential or business address of Grantee)
Koenig Dickinson&Dalluge,PLC
Samuel R.Dalluge, Esq. Cube,Inc.
1850 West Wayzata Blvd. 3555 Crystal Place
PO Box 681 Orono,MN.55391
Long Lake,MN.55356
952-449-9070
samikddlaw.net
MUT
11101TITLE
5151 Edina Industrial Blvd.,Suite 500,Edina,MN 55439
P 952-8446200 I F 952-886-6800 I License No.40273928
RESIDENTIAL PROPERTY BILL OF SALE
In compliance with the terms and conditions of the Purchase Agreement between Estate of Dean Young Seller(s)and
:Cube, Inc., Buyer(s);
Seller(s) do hereby sell and convey to the Buyer(s), their assigns or heirs, the personal property itemized in the Purchase
Agreement and now at the property located at:
3555 Crystal Place, Orono, MN 55391
Seller(s)warrant that the above personal property is free from all encumbrances, except the following (if any):
Date: March 15, 2018
Estate of Dean Young
C , ` 7t i
By: Sandra J.Sw n,Personal Representative
This instrument was acknowledged before me on aloa[ l by Sandra J. Swenson as Personal
Reoresentative of the Estate of Dean Young.
Notaryi'ublic
NOTARIAL STAMP OR SEAL(OR OTHER TITLE OR RANK)
} F MICHELLE RMUE
BNER
rM .. ) Notary Pubticr
s� 1rCncommission
8t 2022
kik, ,
EXHIBIT"A
Legal Description
File No. 2164018-01604
Lots 6 and 7, Block 3, "Navarre Heights," Hennepin"County, Minnesota.
(Top 3 inches reserved for recording data)
AFFIDAVIT REGARDING BUSINESS ENTITY Minnesota Uniform Conveyancing Blanks
Form 50.1.3(2011)
State of Minnesota,County of Hennepin
Roman Zhuk being first duly sworn,on oath say(s)that:
1. (They are)( he is)the President and the respectively,of Cube,Inc.,a
Corporation under the laws of Minnesota, (the "Business Entity"), named as
in the document dated
and filed for record ,as Document No. (or In
Book of ,Page )in the office of the 0 County Recorder 0 Registrar of
Titles of Hennepin County,Minnesota.
2. The Business Entity's principal place of business is at
and the Business Entity's principal place(s)of business during the last ten(10)years has/have been at:
3. There have been no:
a. Bankruptcy or dissolution proceeding involving the Business Entity during the time period In which the
Business Entity has had any interest in the premises described In the above document("Premises").
b. Unsatisfied judgments of record against the Business Entity nor any actions pending in any courts,which
affect the Premises;
c. Tax liens against the Business Entity;
except as herein stated:
4. Any bankruptcy or dissolution proceeding or record against business entities with the same or similar names,
during the time period in which the Business Entity had any Interest In the Premises are not against the
V \ p
Business Entity. I,/� (5 �f
5. Any judgments or tax liens of record against entities with the same or similar names are not against the
Business Entity. /'\
6. There has been no labor or materials furnished to the Premises for which payment Vhas nnott been rttade.
7. There are no unrecorded contracts, leases, easements, or other agreements or\ es rel the
Premises except as states herein: ((��
8. There are no persons in possession of any portion of the Premises other than pursuant to a recorded
document except as stated herein: /����1
Y v
9. There are no encroachments or boundary One questions affecting the Premises of which Affiant(s) (has)
(have)knowledge.
{N.t✓
Page 1 of 2
Page 2 of 2 Minnesota Uniform Conveyandng Blanks Form 50.1.3
Affiant(s) know(s)the matters herein stated are true and make(s)this Affidavit for the purpose of inducing the
passing of title to the Premises.
Affiant(s)
Cube,Inc. .�
BY:
,man -k r/`
,tt
Pres a,
Signed and sworn to before me on February 23,2018,by Roman Zhuk.
0044-ks SARA KIM ANDERSON f (signature of notarial officer)
I
e
NOTARY PUBLIC
MINNESOTA Title(and Rank):
My Commission aspires Jan 31,202a I My Commission expires:
(month/day/year)
THIS INSTRUMENT WAS DRAFTED BY:
Executive Title
3217L Galleria
Edina,MN 55435
QUALIFIED SUBSTITUTE
STATEMENT OF SELLER CERTIFICATION OF NON-FOREIGN STATUS
Buyer(s): Cube,Inc.
Seller(s): Estate of Dean Young
File No: SA18020108
Property Address: 3555 Crystal Place,Orono,MN 55391
Section 1445 of the Internal Revenue Code provides that a buyer withhold fifteen percent(15%)of the
property sale price if seller is a Foreign Person as defined in Section 1445(f)(3).
Section 1445(b)(2) allows an exemption to buyer's withholding requirement when the seller provides
the buyer with a Certification of Non-Foreign Status executed under penalty of perjury stating the seller
is not a Foreign Person and Includes the seller's legal name, tax identification number and home
address.
Section 1445(b)(9)allows the seller to appoint a qualified substitute to provide a statement to the buyer
executed under penalty of perjury, stating that the qualified substitute is in possession of the seller's
Certification of Non-Foreign Status.
The undersigned,being first duly sworn under oath,states under penalties of perjury that:
1. Estate of Dean Young,the Seller has appointed as the Seller's Qualified Substitute as defined in Section
1445(f)(6).
2. ,as the Qualified Substitute,
a. Makes no representation regarding Buyer(s) FIRPTA obligations or the validity of the Sellers
representations on the Seller's Certification of Non-Foreign Status;
b. Is in possession of the Seller(s)executed Certification of Non-Foreign Status
EXCEPT: ;
(Name of any SeNernol providing an executed CeMficafion of Non-Foreign Stalin)
c. Agrees to electronically store the Certification of Non-Foreign Status for a period of 6 years;
d. Agrees to provide the Seller's Certification of Non-Foreign Status to the IRS If requested;
e. Has not received any notice that the Certification of Non-Foreign Status Is false;
f. Has authorized me,'s employee and closer,to execute this Statement on behalf of.
3. I, "4-Nti-►`r - •n, - d anno/don of a false Certification of Non-Foreign Status nor do I
ha
VII IJII4iV
closed-- - ent Agent
r
STATE OF 1 I �t l:
COUNTY s. :JArit4lil10
Sworn to and subscribed before me this 1.. lay of RAO 201=.
--- MICHELLE R HUEBNER
Nat* "�~;-� rr - ,- Notary Public-Minnesota
;- My CommIselon Expires Jan 31,2022
1 BUYERS)ACCEPTANCE OF QUALIFIED SUBSTITUTE STATEMEN ,i i '' " ' A 10 0
I. EMPLOYEES ARE NOT AUTHORIZED BY LAW TO PROVIDE ADVICE REGARDING ANY LEGAL OR
TAX MATTERS.
II. BUYER(S) ARE ADVISED TO SEEK LEGAL AND TAX ADVICE REGARDING FIRPTA AND FIRPTA
COMPUANCE.
III. 'S ONLY LIABILITY IS AS THE HOLDER OF THE CERTIFICATION OF NON-FOREIGN STATUS AND
THE CERTIFICATION AS STATED ABOVE.
IV. BUYER(S) ACCEPT 'S QUALIFIED SUBSTITUTE STATEMENT AND HEREBY INDEMNIFY AND
HOLD HARMLESS FROM ANY LOSS OR DAMAGE RESULTING FROM THE BUYER(S) FIRPTA
OBUG• 'ON' -!r- THE SELLER' ` - ION STATUS.
Cube,In ;!
Aggif ^ C;,...27,„ g 7.,. .
'' Date
2 of 2 Rev.7.26.15
Codification of Non-Foreign Status(Personal Representative) SA18020108
CORPORATE RESOLUTION
Cube Inc.
WHEREAS,the Corporation desires to grant signing authority to certain persons described hereunder.
RESOLVED,that the Board of Directors is hereby authorized and approved to grant signing and authority
to conduct business to Roman Zhuk, President.The foregoing signing,and authority granted shall
include the purchase of the property at 3555 Crystal Place,Orono,Minnesota,55391.
The undersigned hereby certified that he is the duly elected and qualified President and custodian of the
books and records and seal of Cube, Inc.and that the foregoing is a true record of a resolution and that
said resolution is now in full force and effect without modification or rescission.
IN WITNESS WHEREOF, I have executed my name as Roman Zhuk and hereunto affixed the corporate
seal of the above-named corporation this -29 day of 1 , 2018.
•m• Zhuk, Pr ,. i
DEPARTMENT •
.OF REVENUE
Electronic Certificate of Real Estate Value
eCRV ID: 778961 Hennepin County Auditor ID:
Submit Date:02/26/2018 12:48 PM Accept Date:
Buyers Information
Organization name: Cube, Inc.
Address:35 Nathan Lane N#119, Plymouth, MN 55441 US
Foreign address: No
Phone number: 6519833277 Email:
***MN Revenue does not display SSN/Tax ID fields due to privacy. ***
Comments:
Sellers Information
Organization name: Estate of Dean Young
Address: 1749 Sumoch Lane, Mound, MN 55364 US
Foreign address: No
Phone number:9524724582 Email:
***MN Revenue does not display SSN/Tax ID fields due to privacy. ***
Comments:
Property Information
County: Hennepin
Legal description: Lots 6 and 7, Block 3, "Navarre Heights,"Hennepin County,
Minnesota.
Deeded acres: 0.00
Will use as primary residence: No
What is included in the sale: Land and Buildings
New construction: No
Property Locations)
Property location: 3555 Crystal Place,Orono, 55391
Parcel ID s
Parcels to be split or combined: No
Primary parcel ID: 17-117-23-43-0028
Additional parcel ID(s):
Use(s)
Planned use: Residential/Single family home
Primary use: Yes
Prior use: Residential/Single family home
Sales Agreement Information
Date of Deed or Contract: 02/22/2018
Purchase amount: $105,000.00
Downpayment amount: $105,000.00
Seller-paid amount: $0.00
Delinquent Special Assessments Paid by
Buyer: $0.00
Financing type: Cash
Personal Property
Personal property included: No
Sales Agreement Questions
Buyer leased before sale: No Lease option to buy: No
Seller leased after sale: No
Minimum rental income guaranteed: No Partial interest indicator: No
Contract payoff or deed resale: No Received in trade: No
Like exchange (IRS section 1031): No Purchase over two years old: No
Supplementary Information
Buyer paid appraisal: No Appraisal value: $0.00
Seller paid appraisal: No Appraisal value:$0.00
Buyer and seller related: No Organization tax exempt: No
Government sale: No Foreclosed, condemned or legal proceedings: No
Gift or inheritance: No Name change: No
Buyer owns adjacent property: No
Public promotion: Yes
Significant different price paid: No
Comment on price difference:
Submitter Information
Submit date:02/26/2018 12:48:28 PM
Submitter: Executive Title
Organization:
Email: sara@etofmn.com
Phone number: 7632530471
Comments:
Terms Acgepteid by the Submitter:I declare under penalty of law that I have examined the information entered and submitted on this form,
and,based on what I know and believe to be true,the information entered on this form is complete and correct.
ORONO clic ,
Minnesota State Energy Code Calculations and Mechanical Code Requirements Form
Additional copies can be found by going to: http://www.dli.mn.gov/CCLD/PDF/sbc 1322 cert.pdf
.----
Builders Certificate 033 / \ � i Q) Site Address: 3 '� ����'.S \ /a-\ P L .
Builders Name'Com{xa� Date: �
Contractor Name: d <. \ ._ License Number: V:=c 10S`DQ3
Location Type of Installed Type Location Size
Insulation R--Value rr
Makeup Air k2t v 5'-(.- 6
Roof/Ceiling B Io—vl 42 -3 O
Combustion Air P A c , e V>5/ti'-'- 7) "
Walls �iB i:29itic R- a
Water Heating - 4-t✓ .. $S/'1-1-
Slab-on-Grade
FloorMIN0yenak3i,
Ducts Outside of Cendflioned Spaces _
Rim Joist F OA M cz ---z i
Interior,Exterior or Integral Location R-Vague
Foundation Wall PO lyS ky R,. P-- -20 f-G� IZ--a
Interior,Exterior or Integral
Average ti-Factor Stt (solar heat gain chit) Passive Active
Fenestration to/ t7 r Radon Control /IX.
❑
Tyne I t Rating E Manufacturer Model C lcuiatecl Heat Loss
Heating System C.i0--> �0.4t. ) Cfc f i--(l4 L/ C Ai55 97 696e4'
AZ.-
Tyne Rating SEER Ma facturer Model Cooling Load/Heat Gain
SQ
Cooling System -Lr/r� G ifin- 1, `ear/-// (3 2.‘-)-s'O
T - Location Continuous Ventilation Total Ventilation
Mechanical Ventilation � /35'774- r(1
Packet Last Updated. August 2015
Page 20
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