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� ,���` City of Orono FO�USE ONLY <br /> t '�Y p� <br /> O{, O P.O.Box 66 Date Received: / /� Nermi[# 02��0 -� �0 <br /> �,, 2750 Kelley Park��ay <br /> a ,;11���,<<���� � Crystal Bay,MN 55323 Amount: $ � C.U.P Filed: <br /> ��',1I���'P�V'�,�� (95'_l 249-4600 <br /> a <br /> ��x� Approved By;-���_ Site Plan: <br /> l <br /> Recommends: A rova� Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All pennits must be approved by the Building Official and/or Zoning Department) <br /> Job Site/Owner Inforniation: <br /> Site Address: �� � � ����;� P�� �, � o.� • �� � �'`� � <br /> ✓ <br /> Owner: ,..—.C��� � 4 � � � Mailing Address: G/�-y� �/�' �'t�� L�--� <br /> � �-.. <br /> City: % � � v Zip: �.�.� 3.� � <br /> Home Phone: �� .�� �� ����� ���Alternate Phone: ��� � ��� C� - t��(�� <br /> 7 <br /> Contractor/Applicant�Information: � ��r �;��,_ ; <br /> ,,�c. -� l� i.. v'�'Jef�v <br /> Contractor/App.: � -n_S;�..�� � ,��,,.�� Contact Person: �o ^� � r 7�.-��-.c,.� <br /> � <br /> Address: �v �� N. a�� v `��v�°� State License #: <br /> City: �^JO r'��� Zip: _S.S�.�� Expiration Date: <br /> Phone: (p/�'02 �� "" �/O.S Alternate Phone: y�� � �y� �� / � <br /> ����`; � �; ..,, .�°"�:�'T`YpES`UF I7SER�:DEFINED PERMITS •' ' . � ;�':#' � "°��; , <br /> ❑ Stairway to Lake ❑ Retainin Walls ❑ Temporarv 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(tvon-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+Cub1C Ya1'ds � <br /> ❑ Residential- $30.00 $50.00 (Needs C.U.P.) ` Z'�"'�/��r`� <br /> � v <br /> ❑ Tree Removal � /`r� c � �r' <br /> General-User Defined / <br /> *Within 0-75' -$30.00 �� �} �'�_�� �--� �., ''_ � ,� <br /> ✓� <br /> SL" -r t2 f-,,{� c � .-K �-ti- T,; <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 pernlit;and that the wark <br /> will be in accordance with the approved plan. <br /> ------- <br /> � - / �2 � �� � <br /> Applican _�� ___ Date ' � <br /> �Lt/'''..� �� Nser DeSned Pemvt OS/O8/49) <br />