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SQA. City of Orono FOR SIT�SE ONLY <br /> o P.O.Box 66 Date Received:/2///3 D7 Permit#)'/77„5' <br /> 2750 Kelley Parkway <br /> Crystal Bay,MN 55323 <br /> $", (952)249-4600 Amount: $%,...70/ /00 C.U.P Filed: <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 Informat <br /> Site Address: '/;a 7 <br /> Owner: 5jr"-?cl L /©Sra Mailing Address: 6i-, e <br /> City: Dif'4iit; Zip: <br /> Home Phone: 95'"2 -35-3--y 120 Alternate Phone: 43 3--`' --2€'j <br /> Contractor/Applicant Information: <br /> Contractor/App.: f �i <br /> doc/� 7- Contact Person: Tji-7-7 <br /> Address: 4715.-5-d 5 i) P pr State License#: <br /> City: Zip: 5-5--S62/ Expiration Date: <br /> Phone: 'j7/ F5 3 Alternate Phone: {%2-7c.,e <br /> TYPES OF USER DEFINED PERMITS <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 /> Yi 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: $ 25.660 $50.00(Needs Site Plan) <br /> Ge eral-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 <br /> work will be in ccordance with the approved plan. <br /> / .4) <br /> 2 4-1. <br /> Applicant Date <br />