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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 />1117 <br />Job Address <br />j ? j/ ) ? ? T-.; w. I - .4-tc F - ' ? I r( <br />Tract <br />Legal Lot No BIk <br />1. Description <br />Owner Mailing ddress Zip Phone <br />2. Thy: k.. t'LS ii,.- U'Z-t-- %:= ) -iZ -d• c1-- e -il`I E F1-4.17 <br />- -)- 4CS'= <br />Applicant Mail i Address Zip Phone <br />3. Lt i 2 1 tn.; ('-� L v_&.:.'._ 6 r, L Uvv (�( l Icl a., r icy <br />f > c 1. <br />Architect or Engineer Mailing Address / Zip Phone <br />4. <br />Contractor Mailing Address Zip Phone <br />5. ;±/L'-'( <br />Purpose of Fill or Excavating <br />6. C C».-0..e. c r Lp a e r <br />Type and Amount of Fill or Excavating <br />7 <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 -32270 <br />$ <br />State Surcharge <br />G- 101 -20821 <br />, S-c'D <br />TOTAL FEE PAID <br />$ 5-3 &°' <br />Signature of Contrac on, r Aulhoriz,pd Agent <br />Date <br />Si• .. .: 0L►�„111�! -, actor) Dale <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 />2 <br />Permit Validation <br />Ck MO Cash <br />Total Fee Collected $ <br />By <br />