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�Q� City of Orono FOR CITY USE ONLY <br /> %0�� �� P.O.Box 66 �%t�S Permit# ND�/� <br /> � 1 2750 Kelley Parkway Date Received: P C/ <br /> �� �li���.�- �� Crystal Bay,MN 5�323 <br /> / �'"�� ±'iv�G�� 952 249-4600 � <br /> ��o��� � � Amount: $ C.U.P Filed: <br /> Approved By:C�%�� Site Plan: <br /> Recommends: A roval � Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> � (All permits must be approved by the Building Official a�d/or Zoning Department) <br /> Job Site/Owner Information: � �� � <br /> , ,/'� <br /> Site Address: ��Z ` ' �Gl�(�� %/"C�� � ZiC•�� / /� s.��Cf/ <br /> Owner: �Cc� ���e �-G�/^/�=� MailingAddress: 3�y7 �Ce-S� l_-/v-� <br /> City: � ?���G�- Zip: ����l� <br /> Home Phone: �s� 7 7� c7 v� �� Alternate Phone: � <br /> Contractor/Applicant Information: <br /> Contractor/App.:�v//.f� Ln�UD.SCROm4 L[..� Contact Person: U �c r /.� <br /> Address: �$SS' E��L� Qs���4 c�2c�� State License#: ,��D <br /> � <br /> City: /tE _ Zip: �S7 Expiration Date: <br /> Phone: `1(�3 a 7 q " b`j 70 Alternate Phone: (�,� Z 9 j$ --78.�'3 <br /> � ` � �� �� ����� ��� TYPES OF USER�D�FINED PERMITS � � � <br /> ❑ StairwaY 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—42"or Greater � Land Alteration �W <br /> General—User Defined Surcharge � Z'ieneral—User Defined Ge d �s"ePDefine <br /> ❑ Commercial—(Per UBC) �'0-500 Cubic Yards - one-$30.00 <br /> * Estimated Cost: $ $5�.0�(Needs Site Plan) <br /> General—User Defined ❑ 501+CublC 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 <br /> work will be in accordance with the approved plan. <br /> �� (v�/��.�� O /� oS <br /> Applicant � � Da e � � <br /> � µ =' <br /> � �' Reset Form E���+�p�sana�o.a> <br />