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R <br /> ,¢Q City of Orono FOR CITY USE ONLY <br /> G P.O.Box 66 Date Received: j..15Permit 4 -I 4 <br /> 1. /2750 Kelley Parkway J JIM .1 1(" <br /> ii- <br /> (01117:- <br /> � <br /> 46 {r 4- Crystal Bay,MN 55323 <br /> N)10.‘:4,0 (952)249-4600 Amount: $ S C.U.P Filed: <br /> Approved By. .O , Site Plan:7-)Z.-40 e <br /> Recommends: Approval.Approval ET Denial 0 <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: cX 7°?5 ii(7a,24.,,v Qh bp- <br /> Owner: J ,vp ,14.,,,:_c Mailing Address: c2 ''S mAt„64.4...4 <br /> City: LOh Z- 11--C A Zip: 373-2 `a <br /> Home Phone: - 9 73 _7 -67 Alternate Phone: 73-) - 70 - O/c / <br /> Contractor/Applicant Information:? <br /> • ci-- awl? <br /> Contractor/App.: 71744iA-2e- a ie Contact Person: Vow f:c"L;�?��-"lea)._, <br /> 0 <br /> 9 /if/IA 776. a <br /> Address: moo/'/ fle,�,v €,,,,j,,,r Rd State License#: <br /> City: l/;G cr.`4_ Zip: bT 3 `c Expiration Date: I/k <br /> Phone: $.3./..-”,...g- a is-s---' Alternate Phone: 7. --.)--”'3-- F 70 <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 /> ❑ Docks-42"or Greater [Land Alteration ❑ Zoning Review <br /> General-User Defined Surcharge General-User Defined General-User Defined <br /> ❑ Commercial-(Per UBC) 2-15--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 S-1-A-1 /a AA, A ,-4i,v,l\ C 4 G 1 <br /> General-User Defined � <br /> *Within 0-75' -$30.00 ri 6 M 11A 0 S 4 S.1i4i <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 w. 1 be in <br /> J. accordance with the approved plan. <br /> ' C.- =) "7.-° <br /> licant Date <br /> ..':Reset Form (Uses Defined Permit 3/18/04) <br />