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,¢��, City of Orono FOR CITY USE ONLY <br /> P.O.Box 66 Date Received: Permit# <br /> ��,..�,, � 27j0 Kelley Parkway � <br /> � ��'�r���. � Crystal Bay,MN 55323 Amount: $ C.U.P Filed: <br /> �' 'i����+;��h�,� (952)249-4600 <br /> ��HO$ Approved By: o���� Site Plan: <br /> Recommends: A roval Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All pem�its must be approved by the Building Official and/or Zoning Department) <br /> �7ob�Site/Owner Information: <br /> . J , . �° <br /> Site Address: � � <br /> Owner: �2� � l�D�� Mailing Address: [ �� 1�3� ��� j� <br /> c�ty: (��� z�p: Me-�,.�� �53�y <br /> Home Phone: / � Z: ��z ��3 � Alternate Phone: <br /> Connactor/Applicant Information: j <br /> , <br /> Contractor/App.: v]`r'�e—���4,� ��VN1��j�Contact Person: ��� � � <br /> Address: Jr�ZS C�Ct�i 7�i:� Q12 State License#: �-�17��' <br /> c�ty: /�c�Ie ��f� z�p: .�S 35 9 Expiration Date: ��� <br /> Phone: ��3^`17� � '0 y � Alternate Phone: �Z- 3"� ��06 s�j <br /> TYPES OF USER DEFINED PERMITS <br /> ❑ Stairwav to Lake �etaining Walls ❑ Temporary Trailer <br /> General—User Defined Surcharge General—User Defined Surcharge General—User Defined <br /> * (Per UBC) * (Per UBC) � * $30.00 <br /> *Estimated Cost: $ *Estimated Cost: � <br /> ❑ Docks—42"or Greater ❑ Land Alteration ❑ Zoning Review <br /> General—User Defined Surcharge General—User Defined General—User Defined <br /> ❑ Commercial—(Per UBC) ❑ 0-500 Cubic Yards *For 0-75'Zone-$30.00 <br /> *Estimated Cost: $ $50.00 (Needs Site Plan) <br /> General-User Defined ❑ 501+Cubic Yards <br /> ❑ Residential- $30.00 $50.00 (Needs C.U.P.) <br /> ❑ Tree Removal <br /> General—User Defined <br /> *Within 0-75' -$30.00 <br /> I herby apply for a User Defined Permit and I acknowledge that the information above is complete and <br /> accurate; that the work will be in conformance with the Ordinances and Codes of the City and with the State <br /> Building Code;that I understand this is not a permit and work is not to start without a permit;and that the work <br /> will be in accordance with the approved plan. <br /> Applicant Date <br /> (User'De6ned Pcrurit 3l18t04) <br />