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�'-�-�� <br /> � , Cit of Orono �b �Q <br /> .¢,�,� Y I� FOR CITY USE ONLY <br /> ' 0 Q P.O.Box 66 Date Received: ;rd����F Permit# ����5� <br /> �;,;p,,,� 27�0 Kelley Parkway <br /> .�;�f, <br /> � '�J �.-�F- F Crystal Bay,MN�5�23 Amount: $ S�� C.U.P Filed: <br /> S� $,�k,.i;���.�' ti <br /> �`' '��,'�,:"'r�r:�1h o (95Z)249-4600 � <br /> f,�,- � <br /> �eaxo�' Approved By: %� Site Plan: � � <br /> Iv-�'11-�'� <br /> Recommends: A roval.� Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERI�7IT <br /> (All pennits must Ue approved Uy the Buildin�Official andior Zonin�Depaitinen[) <br /> JoU Site/ Owner lilforniation: <br /> Site Address: �� (� �j C�1rG'1/�/Y�2 0Gt c� <br /> Owner: I��1 � 1 1 vP�I/Li�VI Mailing Address: 4'30 � - ����� <br /> City: ���GC�1 r�-- Zip: ��� � <br /> Home Phone: '�l'�2 �� 2j �Z�"p�D Alteniate Phone: <br /> Conn-actor/ Applicant I�iformation: <br /> Contractor/App.: Contact Person: <br /> Address: State License �: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> TYPES OF USER DEFINED PERI�IITS <br /> 7 <br /> ❑ Stairwav to Lake �RetaintnQ Walls ❑ Telnporarv Trailer <br /> General-User Defined Surcharge Generai-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 ❑ Zonine Review <br /> General-User Detined Surcharee Gen�ral-User Defined General-User Detined <br /> ❑ Conunercial—(Per UBC) �0-500 Cubic Yards *ForO-75'Zone-$30.00 <br /> *Estimated Cost: $ �50.00 (Needs Site Plan) <br /> General-User Detined ❑ 501+CubiC YaTds <br /> ❑ Residential- $30.00 550.00 (Needs C.U.P.) <br /> ❑ Tree Removal <br /> General-User Defined <br /> *Within 0-75' -$30.00 <br /> I herUy apply far a User Defined Perniit 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 pernut;and that the work <br /> will be in ac ordanc ith the pproved plan. <br /> �� � '� � �� � � � <br /> Applicant Date <br /> _ _ __ _. _ <br /> {Usa DeSned,Pttarit 3/1.8l04) <br />