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SQA. City of Orono FOR SIT�SE ONLY o P.O.Box 66 Date Received:/2///3 D7 Permit#)'/77„5' 2750 Kelley Parkway Crystal Bay,MN 55323 $", (952)249-4600 Amount: $%,...70/ /00 C.U.P Filed: Approved By: Site Plan: Recommends: Approval ❑ Denial ❑ CITY OF ORONO - USER DEFINED/GENERAL PERMIT (All permits must be approved by the Building Official and/or Zoning Department) Job Site/Owner Informat Site Address: '/;a 7 Owner: 5jr"-?cl L /©Sra Mailing Address: 6i-, e City: Dif'4iit; Zip: Home Phone: 95'"2 -35-3--y 120 Alternate Phone: 43 3--`' --2€'j Contractor/Applicant Information: Contractor/App.: f �i doc/� 7- Contact Person: Tji-7-7 Address: 4715.-5-d 5 i) P pr State License#: City: Zip: 5-5--S62/ Expiration Date: Phone: 'j7/ F5 3 Alternate Phone: {%2-7c.,e TYPES OF USER DEFINED PERMITS ❑ Stairway to Lake ❑ Retaining Walls ❑ Temporary Trailer General-User Defined Surcharge General-User Defined Surcharge General-User Defined *(Per UBC) *(Per UBC) *$30.00 *Estimated Cost: $ *Estimated Cost: $ Yi Docks—42"or Greater ❑ Land Alteration ❑ Zoning Review General-User Defined Surcharge General-User Defined General-User Defined ❑ Commercial—(Per UBC) ❑ 0-500 Cubic Yards *For 0-75'Zone-$30.00 *Estimated Cost: $ 25.660 $50.00(Needs Site Plan) Ge eral-User Defined ❑ 501+Cubic Yards Residential- $30.00 $50.00(Needs C.U.P.) ❑ Tree Removal General-User Defined * Within 0-75' -$30.00 I herby apply for a User Defined Permit and I acknowledge that the information above is complete and accurate;that the work will be in conformance with the Ordinances and Codes of the City and with the State Building Code;that I understand this is not a permit and work is not to start without a permit; and that the work will be in ccordance with the approved plan. / .4) 2 4-1. Applicant Date