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��� City of Orono FQR�G�I��-U, SE ONLY �, <br /> �¢ ��`� P.O.Box 66 � /A� Date Received: ��y��=�Permit# (�(�� � <br /> ( �� � 2750 Kelley Parl.�vay �` <br /> \� �41 y��:,-- �/J Crystal Bay,MN 55323 �(,� <br /> �'��o�,�� (952)249-4600 � � Amount: $ �� ' C.U.P Filed: �'� '' <br /> , �� � <br /> Approved By: M�f � Sife Plan: !D-y-O (. <br /> l S'Y , <br /> Recommends: A roval,8 Denial ❑ <br /> CITY OF ORONO - USER D INED/GENERAL PERMIT <br /> (All pennits must be approved by the Building Official and/or Zoning Department) <br /> Job Site/Owner Information: <br /> Site Address: � � C�v �� � <br /> Owner: l..�c�.� u G�,�, Mailing Address: �/�� I i�+�< </►5 �-�, <br /> c�ty: � L ' z;p: �55�S� <br /> Home Phone: 1-r,�—c/.�6 ,��/�S Alternate Phone: <br /> Contractor/Applicant Inforrriation: <br /> �� <br /> Contractor/App.: � ��,�5�q1��►�, ��,,�� Contact Person: . ( ''4 Ltf <br /> Address: Q_�, ` `�_ ��'�; State License #: /V <br /> City: � • �- Zip: ��35 h Expiration Date: <br /> Phone: `���c - �/�5'� 6 6 ��� Alternate Phone: � �( �%/�' ��'�"`���� <br /> ' ' TYPES OF USER DEFINED PERMITS <br /> ❑ Stairway to Lake ❑ Retaining Walls ❑ Temporarv 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 ❑ Zoning Review <br /> General-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+CubiC Ya \� <br /> ❑ Residentia]- $30.00 �� � $50.00 Needs C.U.P.) ��j`'ti <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 /> ���ork���' n r with the approved plan. <br /> t/ �z��� <br /> A 'ca _. Date <br /> -� . �.�ReSet F�rm � (UserDefinedPemu[3/18/OS) <br />