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. �������' ' � �1 <br /> ��� , ��` <br /> � � �. <br /> ,¢Q� City of Orono � ��' �1'� \ FOR CITY USE ONLY <br /> ' � Q�� P O.Bo�:66 Q �' � �-. Date Received: �Permit# ; � <br /> ( �� ry 2750 Kelley Parf.tivay � �,� <br /> 6 1��i-+�1'`���� ,•� Crystal Bay,MA'S5323 � ' r / / � <br /> ��+ �k ��ti��� (952 �49-4600 �l< � 3C" <br /> oay )- ,. � Amo t: $ C U.P Filed: <br /> , .. <br /> � <br /> roved By: ►'v►C.i- l.l� Site Plan: � '�-d� <br /> � Recommends: A roval Denial ❑ <br /> CITY OF ORONO -USER DEFINED/GENERAL PERMIT <br /> (All pennits must be approved by the Building Official and/or Zoning Depamnent) <br /> Job Site/Owner Information: <br /> SiteAddress: % ��� �If ��'- r ' �(�lV� <br /> Owner: I��t� '�' ,�i�/�'i� �►'�'�'r�� �� Mailing Address: <br /> City: ����%.�U Zip: <br /> Home Phone: ��Z ' Z 3 � - ��I�/ Alternate Phone: <br /> Contractor/Applicant Information: <br /> ��: r�'-� �i�/'k✓+�<%!i; <br /> Contractor/App.: J �� ���`'� �t��/C� rti'G�""�' Contact Person: ����� �v���l� <br /> Address: ��='- �3� 3��� State License #: �S 3i 3��-j <br /> City: ��2+�� Zip: ��35'� Expiration Date: <br /> Phone: �7� � �- L/�� � � Z6 �/� Alternate Phone: �l2 "���c� "- ��%� � <br /> TYPES OF USER DEFINED PERMITS <br /> 0 Stairwav to Lake ❑ Retainina Walls ❑ Tem orary Trailer <br /> General-User Defined Surcharge General-User Defined Surcharge General-User Defined <br /> *(Per UBC) * (Per UBC) *$30.00 <br /> *Estimated Cost: $ 3 ZOG;u.� *Estimated Cost:$ <br /> ❑ Docks—42"or Greater ❑ Land Alteration ❑ Zonin�Review <br /> Generaf-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: $ $50.00(Needs Site Plan) <br /> General-User Defined ❑ 501�+Cubie 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 f a se Defined Permit and I acknowledge that the information above is complete and <br /> accurate;th the r ill be in conformance with the Ordinances and Codes of the City and with the State <br /> Building ode; t t understand this is not a permit and work is not to start without a pennit; and that the <br /> ���ork w' 1 be ' ordance with the approved plan. <br /> _ 2� � � v� <br /> Applicant _ Date <br /> . �. ReSel FOrCT� � (UserDefinedPeanit3l18/04) <br />