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¢Q" City of Orono FOR I USE ONLY <br /> P.O.Box 66 d Lr,� <br /> Q, Q �f J Date Received: Permit 4 rTi� <br /> �Cy t 2750 Kelley Parkway W <br /> 1 y Crystal Bay,MN 55323 <br /> � toy (952)249-4600 Amount: $ C.U.P Filed: <br /> Approved By: Site Plan: c <br /> l ,commends: Approval ❑ Denial <br /> c�✓ KLA-1per " <br /> CITY OF ORONO -USER DEFINED/GENERAL PERMIT D� <br /> (All permits must be approved by the Building Official and/or Zoning Department) a 3-0011(o <br /> Job Site/Owrer Information. <br /> Site Address: <br /> Owner: Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor/.App .ca it Information <br /> Contractor/App.: Contact Person: <br /> Address: State License #: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> TYPES:OF:USER DEFINED?ERrvIITS' <br /> ❑ Stairway to Lake ❑ Retaininiz Walls ❑ Tern]2orary 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 1��rkind iolt zu�(t 1 WCIVk <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 <br /> work will be in accordance with the approved plan. <br /> Applicant Date <br /> Reset Form (User Defined Permit 3/18/04) <br />