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,��,�` City of Orono FOR CITY USE ONLY <br /> �y <br /> O= O P.O.Box 66 Date Received: �'3 'a`'l Permit# <br /> a;,;r:.�,�,_ 3750 Kelley Parkway <br /> L � � ,�'�Jj- F Crystal Bay,MN 55323 Amount: $ C.U.P Filed: NO <br /> �'�'�r�+�1���� (952)249-4600 <br /> �KO� Approved By:�� Site Plan: t�P 5 <br /> Recommends: A roval Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All pein�its must be approved by the Building Official and/or Zoning Department) <br /> Job Site/Owner Infornlation: <br /> Site Address: %� � � � �{%e, � �-�� ►�1��IS �G'L)'7L <br /> f, // � <br /> Owner: � t��� f � 1/�� � ��� Mailing Address: ��J �G�'�'� ��:��� <br /> City: �./�� i� J Zip: -�'�?h �� <br /> Home Phone: �f Sn "( i',�`�� `'�y Alternate Phone: ���.,2 ?�� ;� `�:-�� <br /> Contractor/Applicant I�iformation: <br /> > ,, ,f;,.; � �'�,��� <br /> Contractor/App.: f C��,� ,�� Contact Person: �Gr�(c: ����- <br /> Address: ��� 5� �S ,`� S�- 1�� State License #: <br /> City: ✓��C����%���,Lr,r�Zip: S.� Expiration Date: <br /> Phone: �>> 2 �yJ� 7C Y�G Alternate Phone: <br /> TYPES OF USER DEFINED PERMITS <br /> ❑ Stairwav to Lake ❑ Retaining Walls ❑ Temporarv 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 ❑ Zoning Review <br /> General—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: $ $5�.�� (Needs Site Plan) <br /> General—User Defined ❑ 501+CubiC Y3rds <br /> ❑ Residential- $30.00 $50.00 (Needs C.u.�.) <br /> ❑ Tree Removal <br /> General—User Defined <br /> *Within 0-75' -$30.00 <br /> I herUy 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 pernlit and work is not to start without a permit;and that the work <br /> will be in ccordance with the approved plan. <br /> , ���/� <br /> Applicant Date <br /> (User DeCuied PemvY3/18/04) <br />