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(1.:,;( 11.-:‘):c. <br /> \� City of Orono FOR TY E ONLY <br /> `►� Box 66 <br /> 0, P.O.0 `Date Received: �� 9p <br /> h. 2750 Kelley Parkway �,7�� © ermit# <br /> . iI ii�qi!L ' Crystal Bay,MN 55323 '�1 DO`�-GT�d" � Q <br /> ��wtri;�~oa (952)249-4600 <br /> Rfmcot` Amount: :$ Cll.?Filed: j ilf f N.d <br /> Approve By: r/ O Site Plan: <br /> Recommends: Approval Denial ❑ <br /> CITY OF ORONO USER DEFINED/GENERAL PERMIT <br /> (All permits must be approved by the Buil ding Official and/or Zoning Department) <br /> r <br /> Job'Site,/Owner Information <br /> Site Address: 'c) 10 4.2.44f /81UJ <br /> Owner: Gvik1,4,1... Ca„ w G/,,) Mailing Address: <br /> atri Cti-1-F4,4-4 gkci <br /> City: C'tov4G Zip: <br /> Home Phone: Gid - .StGl - SSU 3 Alternate Phone: ciSc't - 9g- �f.Z./ <br /> Contractor/Appllca st Iriformatibt <br /> Contractor/App.: O 0S3 ev,bX t 4.-S c,hS Contact Person: 4c.,.,ti A diet, <br /> Address: 9s.J. / C, i er( l q State License #: <br /> City: J.ej. ,LI') Zip: ..s."15-LS-7 Expiration Date: <br /> Phone: 4/.)-X31-J$1S Alternate Phone: 763_'/ -..-e9V <br /> g Eb-r`. . 4.::..:',.--TYPES OF USER DEEED PERM TS f.::, <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: S <br /> ❑ Docks-42”or Greater ❑ Land Alteration ❑ Zoning.Review <br /> General—User Defined Surcharge General—User Defined General—User Defined <br /> E Commercial-(Per UBC) ❑ 0-500 Cubic Yards *For 0-75'Zone-$30.00 <br /> *Estimated Cost: $ 0.00(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; hat I un• r =nd this ' r/ permit and work is not to start without a permit; and that the <br /> work will be ' acc. e - ' h t. ... oved plan. <br /> Applicant Date <br /> Reset t Form (User DemedPermit 513/04) <br />