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(-)41°.-41City of Orono 7Rac I- X USE°ONLY <br /> P.O.Box 66 Date Received: /A Permit# aWIO Sa.7 <br /> 2750 Kelley Parkway <br /> Crystal Bay,MN 55323 0' <br /> "Amount: $ �C.U:P Filed <br /> �,''�� (952)2494600 1 <br /> \'�as�� <br /> 01( Approved By: SitePlan.Recommends. Approval ] Denial 0 '" " <br /> tN <br /> CITY OF ORONO -USER DEFINED/GENERAL PERMIT <br /> (All permits must be approved by the Building Official and/or Zoning Department) <br /> Site Address: 6/oo aZZ) <br /> G / <br /> Owner: 6i22 j,wt Mailing Address: 2/00 0G SQL /go) <br /> City: .6110 Zip: -S-5-3;23 <br /> ddb +'a - 7V7-006,e <br /> Home Phone: Alternate Phone: <br /> fir{ € ,; 36 ,' �, <br /> ..r � .��_:-_" � .._ x ,� � a��.u'�'" � `7 ' eta /� J /` / <br /> Contractor/App.: /F44 C��--,-v( , Contact Person: ,a/I�- /&4J <br /> ��� S ✓ r z/ s . <br /> Address: &)' 61X2 State License#: c.,2477'719 70 <br /> City: lc>i ysfec Zip: 5539Y Expiration Date: •7f40-zA za/7 <br /> Phone: 320 -2/2 ^ qq/y Alternate Phone: 32-o —?S'S/ <br /> frTnx. <br /> 4,.1 <br /> � _..,._... . ',PES OF USER JJ 1 INED <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-One Time(Non-Lake Mtka) loir Land Alteration ❑ Zoning Review <br /> General-User Defined Surcharge eneral-User Defined General-User Defined <br /> ❑ Commercial-(Per UBC) 0-500 Cubic Yards *For 0-75'Zone-$30.00 <br /> *Estimated Cost: $ $50.00(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 work <br /> will be in accordance with the approved plan. <br /> �,� ; „ <j� ��8-/O <br /> Applicant Date <br />