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Og'OHO City of Orono FOR CITY USE ONLY <br /> ' P.O.Box 66 Date Received: Permit# <br /> VON 2750 Kelley Parkway <br /> hyrJr Crystal Bay,MN 55323 Amount: $ C.U.P Filed: <br /> t�-V (952)249-4600 <br /> Approved By: Site Plan: <br /> Recommends: Approval ❑ Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All permits must be approved by the Building Official and/or Zoning Department) <br /> Job Site/Owner Information: <br /> Site Address: 2'a45 WQ�)''r are C`Q <br /> Owner: -42-101 jck✓15 Mailing Address: <br /> City: Q0i 'VC7 Zip: 5-5356 <br /> Home Phone: �SZ- 70- zJ ! Alternate Phone: 651 -3ow <br /> Contractor/Applicant Information: <br /> Contractor/App.: Contact Person: <br /> Address: State License#: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> TYPESOF USER DEFINED PERMITS <br /> ❑ Stairway to Lake ❑ RetaininQ 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 W Land Alteration ❑ Zoniniz Review <br /> General—User Defined Surcharge ( a ral—User Defined General—User Defined <br /> ❑ Commercial—(Per USC) 0-500 Cubic Yards *ForO-75'Zone-$30.00 <br /> *Estimated Cost: $ A $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 g' i accord e with the approved plan. <br /> I rna'q -z <br /> Z�- <br /> Applicant 3 (�S� Date <br /> {tJsc`Ik6ned Pem�nq 3(18!04) <br />