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I <br /> \Q/ 40 City of Orono FOR CITY USE ONLY ,41--)(11441 <br /> ( d 41.0 P.O.Box 66 .{.tY" ;Tv t ld C) <br /> Date'Received: g a Permit# <br /> V2750 Kelley Parkway <br /> Crystal Bay,MN 55323 <br /> ;�, 4, (952)249-4600 Amount: $ C.U.P Filed: <br /> \ <br /> Approved By: 011414-1"---Site Plan: 9. 5 • 0 <br /> Recommends: Approval,,a' 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: \O\C? W.\�_ 3 3 t.�'.: 1t..g2, Oc,� .c' `3 S-S5 6, <br /> Owner: 76 ry,A.S ( ' c\i, Mailing Address: \DSC) ice`,.\\a.,;LX ; nt,.-C' <br /> City: OXoc t Zip: <br /> Home Phone: W...- (6-24.).-'4U. Alternate Phone: 02:- (� -)--?iS' <br /> Contractor/Applicant Information: <br /> Contractor/App.: Contact Person: --c.'\S"1 S;Tw1 <br /> Address: State License#: Y.t,C. r;,ue.vyc.n . <br /> City: 0-,Q� ,,,. Zip: Expiration Date: <br /> Phone: qcZ..-ZA.Z-.77(c.a)( Alternate Phone: <br /> TYPES OF USER DEFINED PERMITS <br /> ❑ Stairway to Lake Retaining Walls;liCA MO �Dck u. \ ❑ Temporary Tra . <br /> General—User Defined Surchame i ' General—User Defined Surcharge General—User Define <br /> *(Per UBC) '- ' ' ''''' *(Per UBC) *$30.00 <br /> *Estimated Cost:$ *Estimated Cost:$ A01?-00 <br /> ❑ Docks—42"or Great c 1-4G tZ p Land Alteration ❑ Zoning Review <br /> General—User Defined Surcharg JO• 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 Defined84t arils <br /> E Residential- $30.00 $5.O0(L(,Needds--U-P:)1,":S.:,—, 1 <br /> �i't!� <br /> ❑ Tree Removal ��;>' '5,°:. ivw,) <br /> General—User Defined <br /> * Within 0-75' -$30.00 ' 1;1:1'14 -?�r `1 <br /> , ifiOC:,, .,Jail' (i t t)1v1-- ,? 1-.\--6511,- <br /> `T-65tk J'' <br /> ,A J <br /> I herby apply for a User Defined Permit and I acknowledge that the information above is complete and <br /> accurate;that wo will be in conformance with the Ordinances and Codes of the City and with the State <br /> Building d ;tha I u derstand this is not a permit and work is not to start without a permit; and that the <br /> work will,be in ac'orld nce with the approv plan. <br /> C e_ J Gtr ti "Iii; f' ZU� j <br /> App scan Date / <br /> Reset Form (User Defined Ponta 3/18/04) <br />