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� ,¢�� City of Orono FOR CITY USE ONLY <br /> O O P.O.Box 66 Date Received: Z �C`� Permit# �� C .�(C��� <br /> �,� 2750 Kelley Parkway <br /> G� <br /> r, 1�� ��> � Crystal Bay,MN 55323 Amount: $ � � � C.U.V Filed: <br /> �+�'`��ta�`'���y� (952)249-4600 <br /> �agxo� � <br /> Approved By: .0 /11� T/�6ite I lan: <br /> � <br /> .� i � <br /> � Recommends: A roval Denial ❑ <br /> a�.�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 In.formation: <br /> Site Address: `�3�s �,.h;do�uJ cL, L � <br /> Owner: C,�n�,.� �-`n'�o► Mailing Address: �f.3 Z$ C�%�p��.c�c�, <br /> City: �ro� 6 Zip: .5,5.�`-� 9 <br /> Home Phone: �(0 3 '�I Z� ' '�1`� � ! �=� Alternate Phone: S �"�i' �=" <br /> Con�•actor/ Applicant Iuformation: �� � � <br /> Contractor/App.: Contact Person: <br /> Address: State License #: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> TYPES UF 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-One Time (Non-�ake Mcka� � 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 /> *EStlmated COSt: $ $50.00(Needs Site Plan) <br /> General-User Defined ❑ $�1+CUb1C YaTC�S <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 wark 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 in accordance with the approved plan. <br /> � '� 9� a /�- � � <br /> k <br /> Applicant Date <br /> (Uscr Defined PcctniS 95198/Q9) <br />