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CITY OF LITTLE CANADA <br />515 Little Canada Road East <br />Little Canada, Minnesota 55117 <br />(651) 484 -2177 e Fax: (651) 484 -4538 <br />FILLING AND GRADING PERMIT APPLICATION <br />Applicant to complete numbered spaces only. <br />Job Address <br />3 032, L —A(?)c iZE— (- <br />Legal Lot No. elk <br />1. Description <br />Tract <br />Ow/Mr Mailing Address <br />2. sad , �c, In a ?�e Z L o E., <br />Zip <br />t�S 60 ; <br />Phone <br />/vSt -48 gP `% Z. <br />Applicant Mailing Address <br />Zip <br />Phone <br />Architect or Engineer Mailing Address <br />Zip <br />Phone <br />4. — <br />Contractor Mailing Address <br />5. r- zArD 0(2-- <br />Zip <br />Phone <br />Purpose i I9Excavating <br />� n-) <br />6. r x v".. qq .- C0-09, l`J t`t- (.0,----14.9. c T) <br />Type and Amount of Fill or Excavating <br />7. A r,..,< 40c3 <br />Special Conditions <br />8 <br />NOTICE <br />This permit becomes null and void if filling or grading <br />authorized is not completed within 180 days, or if filling or <br />grading is suspended or abandoned for a period of 180 days <br />at any time after work is commenced. Any work not completed <br />within 180 days requires a new permit. <br />I hereby certify 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 />Permit Fee <br />R- 101 <br />-32270 <br />$ 6ick -• 'l) <br />State Surcharge <br />G- 101 <br />-20821 <br />• H V <br />TOTAL FEE PAID <br />$ Qc - Lt <br />�a9 - <br />APR 2 2002 <br />OF <br />Sig T ure�ontract r Authorized nt <br />/ e <br />Signature or Owner (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 />- 2 2 - <br />Permit Validation Ck MO Cash <br />Total Fee Collected $ <br />By <br />