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CITY OF LITTLE CANADA <br />515 Little Canada Road East <br />Little Canada, Minnesota 55117 <br />(651) 484 -2177 • Fax: (651) 484 -4538 <br />FILLING AND GRADING PERMIT APPLICATION <br />Job Addressr <br />(e�t+ev yri ( (e 2orctc{ <br />.9`%5S <br />Lot No. Blk Tract <br />Legal <br />1. Description <br />gwner ,..1 Mailing p.ddress i) Phone <br />2. C'..k�v"(e4 • t,v(- ),z'Y1 1-I-(o Z (t%J �evt'i-'4"W \) it, Rc-( L•ci SS/ 3. yB39c':a- <br />App 4cant Mailing Address Zip Phone <br />3. CC. tMN2 <br />Architget or Ennineer ".- .fling Address Zip Phone <br />4. .%Y- <br />C Ritor., MaiIign Addre.= Phone ... <br />_ <br />Purpose of Fill or Excavatioo , 0..0.1._ <br />6. ('T(1.--rel. e 3C4c0ee i� 1- -IC`t� �' ret (-tC/* t; //e 1 (; 0 <br />_ .' / <br />• Type and Amount of Fill or Excavating -�- . h J P. <br />7. '1)1 y l— ' r % ea, ---- L ' 0 I ( d' f t)c. e. 0 C' `"i `f- k' cz' / et ( \ a-,l,_ L <br />Special ns <br />_ G" ., lC %G,-'02CC [CLt — /Act(cl .' -7?.tc G Cc? Z /a 7 <br />8 <br />trffe) /; 1(.5 " t � 1-cceic � J - Gn ' <br />NOTICE <br />This pe becomes null and void if filling or grading <br />authorized is •ot completed within 180 days, or if filling or <br />gradi 1s susp nded or abandoned for a period of 180 days <br />at a time afte work is commenced. Any work not completed <br />with n 180 day- requires a new permit. <br />I hereb -rtify that I have read and examined this application <br />and know the same to be true and correct. All provisions of <br />laws and ordinances governing this type of work will be <br />complied with whether specified herein or not. The granting <br />of a permit does not presume to give authority to violate or <br />cancel the provisions of any other state or local law regulating <br />filling or grading. <br />Signs <br />Permit Fee <br />R- 101 -32270 <br />State Surcharge <br />G- 101 -20821 <br />$ 37. 6, <br />/ 7t <br />TOTAL FEE PAID <br />Signature.or-Cwner (If Owner Contractor) <br />Date <br />Public Works Director <br />Date <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />WHITE- Inspector <br />CANARY- Customer <br />PINK-Office <br />4- <br />Permit Validation CI< MO Cash <br />Total Fee Collected $ <br />Rv <br />