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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 />Applicant to complete numbered spaces only. <br />:11.19 <br />Job Addres <br />L� ' .... <br />? L -1 TTL .E AtNt p X11] . <br />Lot No. Slk Tract <br />Legal <br />1. Description <br />Owner ailing Address Zip Phone <br />if <br />Applica O Mailing Address Zip Phone <br />3. e <br />d rchitect or , gineer Mailing Address Zip Phone <br />4. <br />Cant actor _ Mailing Address Zip Phone <br />5. _A 06G :. - /r' S"%9 <br />( °y9 <br />rpose of F or Excavating - <br />/ / i <br />6. s 6. r <br />/ter tc7-4 <br />'type and Amount of Fill or Excavating / <br />/ /� 7. %n 0 �CG7 .. <br />_ <br />Special Conditro s <br />`/ <br />/ <br />. - / <br />f'I Nt-S `/ <br />8 )'G, sy . r'G Z, <br />_ <br />NOTICE <br />This permit becomes null and void <br />authorized is not completed within 180 <br />grading is suspended or abandoned for <br />at any time after work is commenced. Any <br />within 180 days requires a new permit. <br />I hereby certify that I have read and examined <br />and know the same to be true and correct. <br />laws and ordinances governing this <br />complied with whether specified herein <br />of a permit does not presume to give authority <br />cancel the provisions of any oth -r st..• <br />filling or •rading �'- .. <br />�'G'� ' ��'"'""�: <br />/ //j <br />if filling or grading <br />days, or if filling or <br />a period of 180 days <br />work not completed <br />this application <br />All provisions of <br />type of work will be <br />or not. The granting <br />to violate or <br />or local law regulating <br />� %1"' <br />"r.da <br />Permit Fee <br />R- 101 -32270 <br />$ <br />State Surcharge <br />G- 101 -20821 <br />OTAL FEE PAID <br />$ <br />Date <br />1 <br />Zetb 1. 7 -ar <br />7S nature of Contractor or Autho Agent <br />Signature or Owner (If Owner Contractor) Date <br />Public Works Director Date <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />WHITE - Inspector <br />CANARY - Customer <br />PINK-Office <br />Permit Validation Ck MO Cash <br />Total Fee Collected $ <br />By <br />