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, ,��� City of Orono FO CITY SE ONLY � <br /> P.O.Box 66 Date Received: S � <br /> o�_ o Pe�,;t# ao�a-oo s <br /> �� 2750 Kelley Parkway <br /> a � � � � Crystal Bay,MN 55323 <br /> ,�' ` Amount: $ .��C.U.P Filed: <br /> � �'��y ,�.�,� �9sz�za9-a600 /v p <br /> ��$ ,// Approved By �r Site Plan: <br /> �Y <br /> Recommends: A roval ,�] Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All permits must be approved by the Building Official and/or Zoning Department) <br /> ;1�ob Site/OwY1er Inforniation: � <br /> ���� � [� <br /> � , <br /> Site Address: �Q' /\ r = �L �, <br /> ' � <br /> Owner: Q�1 ��� �(�/,���n ��i�.��`t�e:t�,l��Mailing Address: �� ��iY"� �� <br /> City: _ <br /> �E����� '������_ Zip• S��-S �' <br /> Home Phone: ?S�` Y�3�c� ���:�_- Alternate Phone: �.-�� �5��--(�..5�l� <br /> }�� <br /> Contractor/A'�'licaxi�'���,r�rYi��c��:�'��, ;� <br /> Contractor/App.: Contact Person: <br /> Address: State License#: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> �� � _�� <br /> ,. w3 �`� ��� .�;a ' �.�����;� TYPES OF USER DEFINED PERMITS �' <br /> , �.. . <br /> �Stairwav to Lake ❑ Retainin 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-One Time �taon-Lake Mtka) ❑ 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: $ $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 work <br /> will be i�brdan���ith the approved plan. <br /> ; ` <br /> .,���C�.:�_.�,�����1 Q��, ����'1(6 <br /> Applicant Date <br /> _ <br /> (User Defined Pemrit'051081091 <br />