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<4,0.11, City of Orono �, r) FOR CITY USE ONLY <br /> 0 P.O.Box 66 to i Date Received: 9-13-or Permit# 440/14-2--• <br /> 2750 Kelley Parkway = i t.0.1, <br /> Pi? �. Crystal Bay,MN 55323aGAmount $ �9. S C.U.P Filed: <br /> • �$0~ (952)249-4600 <br /> Approved By:0/ ,.►. Site Plaa•y,6 S <br /> Recommends: Approval Denial ❑ <br /> CITY OF ORONO - USER DEFINED/GENERAL PERMIT <br /> (All permits must be approved by the Building Official and/or Zoning Department) <br /> -Job Site/OwnertInformation '--...,,,4,,,‘,' <br /> Site Address: /COSal) Z,p/t C�q� g� 0 c, /� <br /> Owner: �0r� F-;5 (- Mailing Address: id1tS-- QJ6 l- /� <br /> J <br /> City: 1/.)�---/Zo IP Zip: -%3`:1 <br /> Home Phone: cl52- `I -I-3177 /A- <br /> Alternate Phone: ( 1 <br /> Contractor:/Applicant Infonnation <br /> Contractor/App.: v C S ,T11/4, Contact Person: I \cA. ee-2 <br /> Address: (0c(53 c S %\-- 'IIICC) State License#: LA tkcCi S1o; <br /> City: 4-�oLLS�� 2 — <br /> Zip: �P Expiration Date: <br /> Phone: I 2- 72(p - (02 77 Alternate Phone: O' -2-F1p-2-LI 2 CI <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: $ (9IZ3 <br /> El Docks-42"or Greater ❑ Land Alteration ❑ Zoning Review <br /> General-User Defined Surcharge General-User Defined General-User Defined <br /> El 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' -$3V0 r Q.s /lam /&I <br /> ' G._ /( <br /> r i( <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 accordanc- wi i e approved plan. <br /> 441. <br /> ,/z... <br /> Applicant Date <br /> Oa Defined Pemvt 3/18(04] <br />