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4�� City of Orono I FOR CITY USE ONLY <br /> o <br /> ( o P.O.Box 66 'f Date Received: 9/20/0(0 Permit# <br /> y-i 2750 Kelley Parkway �V <br /> 'I yy` • t Crystal Bay,MN 55323 1\,� _- -I f <br /> \NYtyC' (952)249-4600 5 Amount: $ S t_./...0 <br /> C.U.P Filed: <br /> efr <br /> Id Approved By:19 Site Plan: /D•/I-0 Jo <br /> Recommends: Approval,6 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: LO 6 a g,i/(9--(,tv - p0,,--0 &. <br /> Owner: (J\ A tLi4cn t 7 ✓i b-yv Leit/ /n1(,- : <br /> io 66 y'aNK/1--,-,,,Ii—/?,e4,4 /0'7 o 17--.)---,v/64-c i/I- A,cola <br /> City: o/z oi-v0 , 'H,v. o,? o,.)o', /ti/N • <br /> Home Phone: (9.5--- -_-. ►{-73 , 93 2 fe Altetitate Phone: (9.caj 'j`7/ - /0/3 <br /> Contractor/Applicant Information: <br /> Contractor/App.: w Ih'/z v-7f P_ ,(444,7_ , ad Contact Person: j19I4 0,62L5 o,) <br /> Address: y4'( -Ali 5 g ''s State License #: 203 90 90 4 <br /> City: 63(4;LS/a2 Zip: ..C-j?.?/ Expiration Date: 03/o 7 <br /> Phone: .4 (.& (PS-6 • 4O0 2 Alternate Phone: C9}zi Y7/ . /6e) <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) g 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 <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 i accordanc ith the approved plan. <br /> s-7 zet-// -a-,-e"=.________ /.;:e cy <br /> Applicant Date <br /> Reset Form (User Defined Pemut3/18/04) <br />