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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 />� <br />PISION41 AND GRADING PERMIT APPLICATION <br />Exc4 -J - IrLui <br />Applicant to complete numbered spaces only. <br />1118 <br />Job Address . <br />,,Z7 K`t. (..k'c._ eK.. -:� 'i 1 t i�? Fo �. ^vi, C:,:: LiTLI: (.:(.: \M\nti:)' yR�.J ...S. .S ll'i <br />Legal Lot No. BIk Tract <br />1. Description <br />Owner Mailing Address Zip Phone <br />2. L,av�K''t.` L, - kel-L -LS'‘ ems.._.\ uctt`CA, -W S ((1 c, 5 "l —Li e; ,•-i -L ec, t. <br />Applicant Mailing Address 1 Zip Phone <br />3. LYhc-a.,.,\ \evL i -. '1/4:'2 -\ tC_t LLjv'— .e.t- (� \t'R�. C ,... >-e0zc r C\ \ _l r t <br />Architect or Engiheer Mailing Address Zip Phone <br />4. <br />Contractor Mailing Address Zip Phone <br />5.\%1a 1 ct .A 1rw icCi'"111 —' -11.53 . <br />Purpose of Fill or Excavating <br />6. J ti cd r Aft e,a 74- J D a 4 d., -- `51JJI -C. <br />Type and Amount of Fill or Excavating <br />7 S'-\\c_ <br />Special Conditions T'' /� <br />8 l \'{'l S t�`Yi.;N', ,, \ \ \ >`C. ( f ^ \.� �� -.�`i. (,k.��1..� \� \ -J `- ".. L(.V%C =n( C- \i"YL -'\✓� \�4'...(' <br />7\A-c Ac.._ Vii.- 40,... - \U 1 Q Pn. . ' Q; u..`= '-c \---\ \:y E-+`a --.> j"\— (L -�., C.. ni - x %� `?.\.-- .r}—i.: " <br />S <br />(11]..�^.)rcti.� -.. ...,�� �,:.... ��` FZ Y,v' \v \z��'S�,..�J �('�= <br />L. <br />NOTICE <br />• <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 />_-- <br /><��v �i� :> r�=�i. L..:: `�t. J -( <br />�� 5 \��- ...- �1 =�,..> <br />Permit Fee <br />R- 101 -32270 <br />$ <br />State Surcharge <br />G- 101 -20821 <br />4'0 <br />" <br />TOTAL FEE PAID <br />$ <br />Signature of Contra. or or A orized Air .- Date <br />Signature or Owner If Owner Contractor) Date <br />K. <br />P. Vic 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 />3 Total Fee Collected $ <br />ph, <br />