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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 />1. 4 <br />Job Address / p <br />b Address (Q 4•Y� { .OGL /t J/ &id /� <br />Tract <br />Legal Lot No. Bik <br />1. Description <br />Owner Mailing Address Zip Phone <br />2. ( /tarh'5 Ile rmeersc /) &26 G.. lc.,ei, /32- 65117 [i? 6;42-41-96--9‘79 <br />Applicant Mailing Address Zip (9)) Gv�(- P52F y5 fs 3 5 ,2e <br />Architect or Engineer Mailing Address - Zip Phone <br />4. 6.ee Z. <br />Contractor Mailing Address <br />5. 11 o put Al Fxcavavin; 2- 3%() (7ocertvr'iWC rag. <br />Zip Phone <br />N /- ro,3tt.a*e T;p 55025' (-4/-97 -7/3f <br />5/p7,/5 °% /10 more srnn) 3- / <br />Purpose of Fill or Excavating <br />6. frOvf4 e rlki- 4411 et c.vt bact (�'c! r(j'/ 5 o FJen <br />Type and Amount of Fill or Excavating <br />7. 32.0 c.y fl Cavti.Fravl 1 ZD 0 -Re iI <br />Special Co ditions - - <br />8 •t a ec •s'i'dle c4 ['c�Yl/ d c1 bok5 rdc /r e'nv11- a,zeYMcnt -r1, krt/ /, <br />r <br />Xie-fitv2 dravaare.. geed tii cn5 will net be GAt--nt-n/. <br />&lo rd-10i 14)1A SS &'nd nal�u -e pL444 7s <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 />�GI�Ga G1l /Ge62---. <br />Permit Fee <br />R- 101 -32270 <br />$ <br />State Surcharge <br />G -101 -20821 <br />TOTAL FEE PAID <br />$ <br />Signature of ontractor or Authoyized Agent Date <br />(''''t Qe 47 Ldp? 2��< ,. /'\- <br />Signature or Owner (If Owner Contractor) Date <br />Public Works Director Date <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS 15 YOUR PERMIT <br />WHITE- Inspector <br />CANARY - Customer <br />PINK - Office <br />Permit Validation Ck MO <br />Total Fee Collected $ <br />By <br />Cash <br />