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, 4�� City of Orono F CIT USE ONLY <br /> /O M Q\, P.O.Box 66 Date Received: Permit# /3� <br /> • ay,� 27$0 Kelley Parkway <br /> � Crystal Bay,MN 55323 !1 Amount: � C.U.P Filed: <br /> r- <br /> ,� ��kr, ,-� �' <br /> + `� y� (952)249-460U 1' , I�� <br /> �'�O� `� �I� .4pproved By: �_ Site Plan: _� <br /> Recommtnds: A roval Denial <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All pertnits must be approved by the Building Official and/or Zoning Department) <br /> y!�r� rdf' k5�•.,' -' A1 (] .;t�j iU,�� L.� <br /> f'++5��.4,� �•�r��f�:'�4`.¢w k � 13��. 'e� i <br /> Site Address: 7�� Q i T S �a r. c�+' <br /> R Q���,..� ��� P� , �,.-f- «� -/ <br /> Owner: ,L��Z�a� 13v y-t�,q „�,.� Mailing Address: 3�F'7 I��� .r.</1�7` e c/t. <br /> c.�a� t�. �.�„ ... .�s3 S/ <br /> City: �Rv�D Zip: <br /> Home Phone: �/�- L/9� —7�-� 3 Alternate Phone: <br /> �Contractor/Applicant Information:_� ; '� <br /> Contractar/App.: �e 1 -� Contact Person: �� �`L "` �J�"�"`'t <br /> Address: .3 8'� J��� a.�� e�2 • State License#: <br /> City: L�C Zip: ��?/ Expiration Date: <br /> Phone: �v/ 2' ��1�� '"�7S 3 Alternate Phone: <br /> � .� � . .. ��� .., ... <br /> ,. , . : , _ , _ <br /> � 3 ,.. .. . <br /> p M <br /> � ' \ ..f . . i { ,� ' <br /> �C-.. � 'S,1 M' <br /> �Stairwav to Lake ❑ Retainin�Walls ❑ Temporary Trailer <br /> General-User Uefined Surcharge General-User Defined Surcharge General-liser Defined <br /> * (Per L1BC) oa * (Per UBC) * $30.00 <br /> *Estimated Cost: $SG�o. *Estimated Cost: $ <br /> ❑ Docks-One Time i?�on-Lake natka� ❑ Land Alteration ❑ Zoning Review <br /> Geneni-User Defined Surcharge General-User Defined General-User Defined <br /> ❑ Commercial-(Per UBC) ❑ 0-500 Cubic Yards *ForO-75'Zone-$30.00 <br /> *Estimated Cost: $ $50.00(Needs Site Plan) <br /> Generat-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 Pernut 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 in accordance with the approved plan. <br /> � _ - �, � -�� <br /> Applicant Date � <br /> t[�=n�a r�n�i�sra�i� <br />