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O¢0 A,O City of Orono FOR CITY USE ONLY <br /> `r P.O.Box 66 Date Received: � Permit#qf��� � <br /> 2750 Kelley P <br /> a "- ,C Crystal Bay,MN 5323 <br /> �r�'��o'yo' (952)249-4 00 Amount: $ C.U.P Filed: <br /> Approved By: Site Plan: <br /> �� Recommends: A rovai ❑ Denial ❑ <br /> CIT F NO-USER DEFINED/GENERAL PERMIT <br /> cmits must be approved by the Building Official and/or Zoning Department) <br /> Job Sit Owner Information: <br /> �. _ <br /> �lte/�C�dfCSS: � �-� .� �-.�.�c'�`T_. , c' �`� .��'�r<•o 4.� <br /> Owner: ,��`'� `'C ��' �r �•_� /L4,��� Mailing Address: <br /> �� <br /> ���;,� � >`� J r7 l � �� � � � <br /> City: Zip: <br /> Home Phone: �-� � 7 " z'�= -l��' �� � Alternate Phone: <br /> Contractor/Applicant lnformation: <br /> � <br /> Contractor/App.: '� « (—��.��� �C--� ;<<- Contact Person: _�= i�✓? �`��`� <br /> � <br /> Address: � �UC� �1�: ��� �f � State License#: L.G�C������� <br /> � � -� <br /> City; �f� ��w��� Zip: �`�G%r L Expiration Date: `�' <br /> c — � _> � . <br /> Phone: � � -� - - �- ` � �`! �-- Alternate Phone: (-�5�- �.�f- `��c�/ <br /> TYPES OF USER DEFINED PERMITS <br /> ❑ Stairwa,y to Lake �Retaining Walls � Temporarv Trailer <br /> General—User Defined Surcharge General—User Defined Surcharge Genera]—User Detined <br /> *(Per UBC) *(Per UBC) *$30.00 <br /> *Estimated Cost:$ * Estimated Cost:$ ��' ��•"�' <br /> --�- <br /> ❑ DoCks-One Time(Non-Lake Mcka� ❑ Land Alteration ❑ Zoning Review <br /> General—User Detined Surcharge General—User Detined General—User DeYined <br /> ❑ Commercial-(Per UBC) 8 0-500 Cubic Yards *ForO-75'Zone-$30.00 <br /> * Estimated Cost: $ $50.00(Needs sice Pian> <br /> General—User Detined � 501+CUbIC YatdS <br /> ❑ Residential- $30.00 $50.00(Needs C.U.r.) � 1�; ��/,' ����� 54.,�J �`,,� <br /> .�X�' <br /> � Tree Removal / "� (� <br /> General—User Defined �`(�� "� y�S'' ` � <br /> �` Within 0-75' -$30.00 C <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 /> work will be in accordance with the approved plan. <br /> � <br /> _7 �_ ,y; l � <br /> -, , <br /> Applicant �-%� D te <br /> Reset Form (Usu Dafined Petmit OS/O8/09) <br />