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,, ,��� City of Orono FOR CITY USE ONLY 2 <br /> \ P.O.Bo�66 Date Received: Ui/S /t�-1 Pecmit# �O 7q✓C' <br /> . ��;,:,:,.,. �� 27�0 Kelley Parkway ���a <br /> � tj�`?�:r:t'- � C stal Ba MN 5�323 <br /> �, ��.tii�,; �, ry Y, Amoun[: $ �' C.U.P Filed: <br /> �' '�i�;�r�t;���,�` �952)249-4600 <br /> � r - - -��$xO� � Approved By: � Site Plan: <br /> d�(!/Z.._/ C.�r � / <br /> �2-/I �_�� � r� Recommends: A roval ❑ Denial ❑ <br /> ,°��,� ��`��''��`�13`�s �a nc� <br /> N��h �� �� �CITY OF ORONO - USER DEFINED/GENERAL PERII�IT <br /> (All perniits must be appro��ed Uy thz Buildine Official and/or Zonin�,Depaitment) <br /> Job Site/ Own <br /> �3� �� ite �d i-�� 1 ' l S � o,n�i �`J C�,�S S �`LC��� � d � � vv�n �U�:_ <br /> �S/ � ,,(� <br /> Owner: C_� G 1�� G(7'd h d' Mailing Address: p- �� �C�C � 6 <br /> City: ��CahG' �'� S ��b Zip: r� 5��� �G� �r�ss 3L3 <br /> Home Phone: l S Z' Z`� �I '��'6� � Altemate Phone: 6 ��= � U ' 3�(�L <br /> : 'pJ C'�rp� CE�� <br /> �c2s�/ Applicant formation: <br /> Ca�r-�ctar�App.: `JE��1�� �9LJ�1 Contact Person: �n.qL� �/f/�QLSy <br /> Address: 'j��J� ,/�/l��rvr� �� State License #: �/'��f <br /> City: ��(�A'�qi�tt Zip: ��7f. Eapiration Date: /��f/' <br /> Phone: ��Z 3� � 1(1��v Alternate Phone: jS Z ��� a1��'� <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 LBC) * (Per UBC) * $30.00 <br /> *Estimated Cost: � *Estimated Cost: � <br /> ❑ Docks—42" or Greater ❑ Land Alteration ❑ Zonin�Review <br /> General-User Detined Surcharee General-User Detined Genzral-User Detined <br /> ❑ Conunercial—(Per UBC) �0-500 Cubic Yards *ForO-75'Zone-�30.00 <br /> *Estimated Cost: $ $SO.00 (Needs Site Plan) <br /> General-User Detined ❑ 501+Cubic Yards <br /> ❑ Residential- �30.00 $50.00 (;�leeds C.U.['.) <br /> ❑ Tree Removal <br /> General-User Defined <br /> *Within 0-75' -$30.00 ��I� � n C_ (,\ r �� �l r}_ <br /> �� �, ` � v �`. <br /> I herby apply for a User Defined Permit and I aclrnowledge 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� un rstand this is not a permit and work is not to start without a permit;and that the work <br /> will Ue ccorda e w h the approved plan. <br /> l �r �� Z�y <br /> Applicant Date <br /> __ _ _ .._ .. _ <br /> (CJsc�,DefinedPrnrrit 3/18l04) <br />