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0City of Orono FOR'C TY USE ONLY <br /> P.O.Box 66 L 2.[ o`f' Date Received: --�-o i Permit# O 77 7 <br /> 2750 Kelley Parkway al I <br /> hki-, <br /> Crystal Bay,MN 55323 Amount: S C.U.P Filed: <br /> (952)2494600 $-'2�-0•( <br /> Approved By: Site Plan: <br /> Recommends: Approval K Denial ❑ <br /> CITY OF ORONO -USER DEFINED/GENERAL PERMIT <br /> (All permits must be approved by the Building Official and/or Zoning Department) <br /> Site Address: 3 -z o,o -+ low U)d�w 4�, 4.,d <br /> Owner: ►MN_. Mailing Address: g4 &/ 2a WrCf <br /> City: Zip: <br /> Home Phone: 95-A ' 73 - 8Q Alternate Phone: - a 9,0 .?A <br /> S,N V1/tvas b z X90 2l to <br /> OT1 aCtOI lAYOU 0"N <br /> P1xt � <br /> RFs , - _ <br /> 5,.�� ��� ��.Q 6�Z- 3 6 6 •I ZZ5 <br /> Contractor/App.: 6�#95 Contact Person: <br /> Address: d,t/2g ,RAO( State License <br /> City: 6041 14 we, Zip: Expiration Date. <br /> Phone: gjr.Z'yl3 "' o1Z9 Alternate Phone: <br /> ❑ Stairway to Lake ❑ Retaining 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 ❑ Zonina Review <br /> General-User Defined Surcharge Gene -User Defined General-User Defined <br /> ❑ Commercial-(Per UBC) f 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 orbbl-tL%p _ pp"�/a p i�j tkuA /1 16W1 Lh (m*within 0-75' -$30.00 lJ I��'�1� rA1T4U 1L)yAJe- NJ <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 ers d this is not a permit and work is not to start without a permit;and that the work <br /> will be in da with the approved plan. <br /> eL <br /> Applicant Date <br /> ftJscr"I)e£�d?�mt�i ;l <br />