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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 />1107 <br />Job Address . <br />Legal C P -\)'- 77ry..t;) --' 64A A & Bik Tract <br />1. Description x j ,. 7,or"t r-) <br />�iv�ner n Mailing Address Zip. Phone <br />2. tv-t lam. G: cJhs. 'hs l� cr, \k.�: "1 L- ".' ; ) _i.:, _, c \. <br />Applicant Mailing Address Zip Phone <br />3. <br />Architect or Engineer Mailing Address Zip Phone <br />4. <br />Contraclos T Mailin<,Address„ - Zip Phone <br />5. eta z \-�&� - 1.�3' -a31- ia3..� �M\\i`��,Q \0\e.�E Ve A 1ck <br />Purpose of Fill or Excavating <br />6. Prat -QA- (1ut,,s,. , ex-i °' � -�._ rtros.G erobla- , ih � 0 -1a4�� <br />Type and Amount of Fill or Excavating <br />7 Tj CCC u\-,C.C. R.,-AS G.. •v -0 . <br />Special Conditions j / Yb j <br />8. c-C.c 3ti C.C- C Yyn v'l vit. eC ( C`n._ 'C, <br />- . cck as kZE cr ciLvr,..4 cf- r . ct ck-L I.r,C--S, \ \cu,z <br />\Cc <br />( J7 <br />�.�C <c � ?Cti % cti`P o`GCE Olt -f`-` 2 ,i1„,,,z_ ( 2< ; t <br />J <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 />.2_01L, • co, <br />State Surcharge <br />G- 101 -20821 <br />, 50 <br />TOTAL FEE PAID <br />$ citc.Sb <br />�@� <br />1 'v <br />( 2001 <br />JUL 3 1 <br />Signature of Contractor or Authorized Agent Date <br />Set c(.t).c-G-t& Sc. n c.: w&s lz(c\ �, \ <br />Si nature or Owner (If 0 vner tractor) Date <br />7 - . -c)-- - 7 1 <br />Publi W rksDirector Date <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PEE FJIMrc : - (' f ,JAN •ut' <br />WHITE-Inspector <br />CANARY-Customer <br />PINK - Office <br />-4 <br />Permit Validation Ck MO Cash <br />Total Fee Collected $ <br />By <br />