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* • 4 <br /> OA) City of Orono : O C V .0 ONLY <br /> P.O.Box 66 <br /> Q <br /> 4: Q DateRecelved ✓: / , 'Permit# / '• <br /> t,.�- 2750 Kelley Parkway i. <br /> .,4c,w Crystal Bay,MN 55323 <br /> +� ,rte, (952)249-4600 -Amount 3 C,U.?Piled <br /> Approved By Site.Plan <br /> Recommends: Approval 0 Denial E:1 • <br /> CITY OF ORONO USER DEFINED/GENERAL PERMIT <br /> (All pennts must be approved by the Buil ding Official and/or Zoning Department) <br /> :Job'''Site i Owner Information <br /> Site Address: / 3 Sa 0&Wel oil w. DR-1 V8 ©0Lii 6 *AI Cs-31Z <br /> Owner: . It iA . L WA 11 <br /> I t.1 iJMailing Address: .SGt;71QZ <br /> City: 0 N0 Zip: cS-3 A <br /> Home Phone: 9 ,R., 6 Z 3 a Alternate Phone: 9 S'd- X38 2,6'C <br /> Colstractor/.Appltca it. fortnatron ,,kf >> A <br /> /J V4k�kC6 thUC71Contractor/App.: 0,1 Contact Person: Ge- <br /> Address: State License#: <br /> City: Zip: Expiration Date: <br /> Tl UE Phone: 9 ,5_a_ Y-1-t 1 -," -9' 3 Alternate Phone: 6 /d d."1-5- <br /> J 7 9"?-3 <br /> ,-.30 .` ?K ,,r ,kg+" ..„:,,, TY;P.E$ OTI:USER D . MO 5 <br /> ❑ Stairway to Lake ,r Retaining Walls 0 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:$..3tCCO <br /> 0 Docks—42"or Greater )/1 Land Alteration 0 Zoning Review <br /> General—User Defined Surcharge Wral—User Defined General—User Defined <br /> ❑ Commercial—(Per UBC)1 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 /> 0 Residential- $30.00 $50.00(Needs C.U.P.) <br /> 0 Tree Removal <br /> General—User Defined j * vg 01-0,-11,1m e/ o,Wi - <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 1 understand this is not a permit and work is not to start without a permit; and that the <br /> work will be in accordance with the approved plan. <br /> , / , 0 B <br /> Applicant Date <br /> Reset F9rm (User Defined Permit 3/18i041 <br />