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4 � <br /> � ,�—��� City of Orono �� � FOR ITY USE ONLY <br /> %��� �A', P.O.Bo�.66 Date Received: �-� U 0 v' Permit#����?�� <br /> { � 1 2750 Kelley Parkway `�t���.,,�,.c <br /> �� �1���;-- �i Crystal Bay,MN 55323 ✓� Q7 <br /> �' '"' r •�G� (952)249-4600 ��. <br /> �_'*� `�� Amount. $ C.U.P Filed: <br /> \�� <br /> Approved By:�`�[��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 and/or Zoni�g Department) <br /> Job�Site/Owner Information: � � �� <br /> Site Address: `=L��� ����yLk '� ��� <br /> : (�wner: ���� ���� ��`" �`V/' Mailing Address: � S�� l�''�«�S'7/c`'c�7' <br /> �' (�.�� <br /> c��: z�p: S�S3R I <br /> Home Phone: �5� ��� ��� Alternate Phone: ��� ��'� �� y� <br /> Contractor/Applicant Information: �� � <br /> Contractor/A �MMEP.�+., �_ 7�� <br /> pp�=__ ��C��� Contact Person: <br /> Address: �1�37 �C �p j�J S� State License #: ��S`� <br /> City: �Clh�.� Zip: 55�2�, Expiration Date: /Y7�� i,'�7 <br /> Phone: 71v3-y"7�-3i.�G3 Alternate Phone: �7b3-� ZZ`1 -23f���y <br /> TYPES OF USER DEFINED PERMITS '- <br /> ❑ Stairwav to Lake ❑ Retaining Walls ❑ Temporary Trailer <br /> General—User Defined Surcharge General—User Defined Surchazge General—User Defined <br /> *(Per UBC) *(Per UBC) *$30.00 <br /> *Estimated Cost: $ *Estimated Cost: $ <br /> � <br /> ❑ Docks—42"or Greater � Land Alteration ❑ Zonin�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 ❑ rds <br /> ❑ Residential- $30.00 $50. u.P.) <br /> ❑ Tree Removal <br /> General—User Defined <br /> * Within 0-75' -$30.00 <br /> I�L�2 - �'o��� 5�,�.� �(s, 3 �� � <br /> I herby apply for a User Defined Permit and I acknowledge that the information above is complete and <br /> accu te;that the work will be in conformance with the Ordinances and Codes ofthe City and with the State <br /> Bui�l�ng Code; that I understand this is not a permit and work is not to start without a permit; and that the <br /> wPrk wi}i be 'n c dance with the approved plan. <br /> . <br /> ��� �-l� <br /> �� <br /> � Applicant - Date <br /> �� �. Re$et F��'m � (UserDefinadPecmit3/18/04j <br /> �'t,:... . __.. <br />