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� ���� City of Orono FOR CITY USE ONLY <br /> '� P.O.Boa 66 <br /> Date Received: Permit# <br /> ��;;,_,,.,. � � 2750 Kelley Parkway <br /> ,� �y`�r�- �'�,� CrysYal Bay,MN 55323 <br /> �� u:�"�4`�`% (952)249-4600 Amount: $ C:U.P Filed: <br /> ��o/ <br /> Approved By:�i'����te 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 Zoning DepaRment) <br /> ��Job Site l Owner Information: <br /> Site Address: ` � ( la C.� ��l �^ ��-'r� t� ,2_� � iZ__ _ <br /> Owner: �-�� � F 1�.v�n i ��•.� r Mailin Address: -7 <br /> g �'� /�iu fvcizf/1. r4n�u Y)•Z. . <br /> c�ty: � �2-° "' Q , zip: _�"��� �y <br /> Home Phone: 1 S z``� � Z' � � �1 S Z . Alternate Phone: i��2-'��-I I-y y I C�. <br /> Contractor/Applicant Information: <br /> Contractor/App.: Contact Person: <br /> Address: State License #: <br /> City: Zip: Expiration Date: <br /> Phone: Alternate Phone: <br /> TYPES OF USER DEFINED PERMITS <br /> ❑ Stairway to Lake ❑ Retaining 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 ❑ Zonin�Review <br /> General-User Defined Surcharge General-User Defined General-User Defined <br /> ❑ Commercial—(Per UBC) {,] 0-500 Cubic Yards *For 0-75'Zone-$30.00 <br /> *Estimated Cost: $ ' $50.��(Needs Site Plan) <br /> General-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 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 /> (�vor�will be in accardance with the approved plan. <br /> !� -�': �~ ' <br /> ��,t J , �---i----` ��.? -�U '� j - <br /> � <br /> Applicant �,... � � � Date <br /> Res�t Form ��� ;:. ��9��;�,���:����i <br /> �._ .�� , <br />