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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 />1107 <br />l,rr ......... ... .......N.,.... .._...__.___� -...,. <br />Job Address +-r- ` <br />\ \ \33 1, W1 l <br />�3�Y e1. <br />_ - .444-0._ <br />Lot No. Blk Tract <br />Legal <br />1. Description <br />'Il -vnor n „M ailing Address Zip` ` Phon <br />2, lit 11e:tJrNzr1-.S ( ) Ors .. Dilia St`rx 1-e_V lu� tyi i"T 14 k .fin <br />Applicant Mailing Address Zip Phone <br />3. <br />Architect or Engineer Mailing Address Zip Phone <br />4. <br />Contractor 7`. Mailin Address„ Zip Phone <br />5. CU-k- °7 \k-Q, -`tb3 -s 4- io3 3 <br />Purpose of Fill or Excavating �) <br />6. Tro +2.4.�- • ko bpi C. 5)aVaSc 4.y_ cL eS.. -- p cola ._ ivy i 0.4 4_41/4_ , <br />f <br />Type and Amount of Fill or Excavating <br />7. $ Coo cvS,Cc, '\S civr-on<. <br />Special nditions <br />8. U S "4 t, c cC <br />�t,iZ <br />-to Ca cis- CAF Cu_vvt�l C�V ec ---- c,Y. 4.ac\C yn°d- F:-- -x_ \i\cu z <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 />0 5 C <br />TOTAL FEE PAID <br />$ o2-` tc, 5b <br />Signature {off Contractor or Authorized Agent <br />(('' <br />Date <br />Signature or Owner (If Owner Contractor) <br />Date <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 />Permit Validation Ck MO Cash <br />Page 201 <br />Total Fee Collected $ <br />By <br />