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,-. a <br /> - • �0��� P.O.Box Orono FOR CIT'Y USE ONLY A� �� v <br /> �, 0 Date Received: Permit# �� <br /> ai.� 2750 Kelley Pukway ����� ����3 <br /> 1 '' ,!, � Crystal Bay,MN 55323 <br /> ����, <br /> ���80�� (952)249-4600 Amount: $ C.U.P Filed: <br /> ���i <br /> Approved By: Site Plan: <br /> Recommends: A roval Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT P� �� �Or' <br /> (All permits must be approved by the Building Official and/or Zoning Department) �� <br /> Job Site/Owner Information: <br /> Site Address: `��U �tt+ Qf�-��,,����., <br /> Owner: �e v�� T'�"'�S t21 Mailing Address: ��Ci (_-;1�e �jr��.,,,y t�- <br /> � <br /> CitY: _ �anc; Zip: �53� � <br /> Home Phone: �S 2- � 7.�� (_`$�� Alternate Phone: �J Z - `J 7�- 3jy� <br /> Contractor/Applicant Information: <br /> Contractor/App.: ���oo� ��c�Tnc. Contact Person: �� ��' <br /> Address: lD� (��(�}�r� S�. �1C'c State License#: � �/ <br /> �� ' �� <br /> Ci ��-�-���S ��,,.��lp: �Z(� Expiration Date: <br /> Phone: � �Z- �2Cc R l��`j� Alternate Phone: �(c�- Z�S� �Zy'Z� <br /> ` '����_��. TYPES OF_USER DEFINED PERMITS <br /> / -- -- -- -- nv -- <br /> ❑ Stairwav to Lake �Retaining Walls �1\�� ❑ Tem or Trailer <br /> General—User Defined Surchar General—User Defined Surchazge General ser Defined <br /> *(Per UBC) *(Per UBC) * .00 <br /> *Estimated Cost:$ *Estimated '� <br /> ❑ Docks-42"or Greater �Land Alteration ❑ Zonin�Review <br /> General—User Defined Surchazge General—User Defined �� � Creneral—User Defined <br /> ❑ Commercial-(Per UBC) � 0-500 Cubic Yards 2�'/ �� *For 0-75'Zone-$30.00 <br /> *Estimated Cost: $ $50.00(Needs Site Plan) �\� <br /> General-User Defined ❑ 501+Cub1c Yards <br /> ❑ Residential- $30.00 $50.00(Needs C.U.P.) <br /> ❑ Tree Removal <br /> Generai—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 /> wor ' accordance with the approved plan. <br /> `� z/ O'7 <br /> App ant Date <br /> Reset Form (UserDe6nedPttmit3/18/04) <br />