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,��� City of Orono FOR CITY USE ONLY <br /> 0: �� P.O.Box 66 Date Received: Permit# <br /> �`a.<.,,. 1 27�0 Kelley Parkway <br /> � ij'�''t'r''- � Crystal Ba MN�5323 <br /> , y ���;_�i:,;�- � Y� Amount: $ C.U.P Filed: <br /> �''if;°Fr�+;{1��,�` (952)249-46C)0 / <br /> ��gxO� Approved By: `��� Site Plan: <br /> Recommends: A roval �-� Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERI�ZIT <br /> (All pennits must Ue approved Uy fhz Building Official andior Zonin�Depaitment) <br /> JoU Site/Owlier I�zforniation: <br /> .�j � � �/ <br /> Site Address: � ���U ��; U <br /> � •\ <br /> Owner: ��//�� � �)�-f�� � Mailing Address: <br /> City: ��V�'�� Zip: <br /> � <br /> . ( <br /> Home Phone: � �2 " �� �` � �� Altemate Phone: ,o j'L � ?� p � �(o k� <br /> Conn-actor/ Applicant I�lformation: <br /> Contractor/App.: 1�°r (��,� . Contact Person: <br /> Address: State License #: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> TYPES OF USER DEFINED PERMITS <br /> ❑ Stairway to Lake ❑ Retaining Walls ❑ Temporarv Trailer <br /> General—User Defined Surcharge General—User Defined Surcharge General—User Defined <br /> * (Per L"BC) * (Per UBC) * $30.00 <br /> *Estimated Cost: $ *Estimated Cost: $ <br /> ❑ Docks—42"or Greater �and Alteration ❑ Zonin�Review <br /> General—User DeYined Surcharae General—User Defined Gen�ral—User Detined <br /> ❑ Conunercial—(Per UBC) []�0-500 Cubic Yards *ForO-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(t�eeds C.u.P.) <br /> ❑ Tree Removal <br /> General—User Defined <br /> *Within 0-75' - $30.00 <br /> I herUy 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 ode;that I u de stand this is not a permit and work is not to start without a permit;and that the work <br /> will b in ccordance it the approved plan. <br /> , �LL � 3l �� <br /> Applicant Date <br /> . _ <br /> (User De6ned Peanit 3l18/04) <br />