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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 />1102 <br />Job Address Kt t- ei2_ T AawAT <br />f�� <br />Lot No. Bik Tract <br />Legal <br />1. Description <br />2. <br />Ow er Mailing ddress Zip Pone <br />l � �i c QEN 6 !GG —C, ;09> Le - Wit'k(-D W/ky <br />% <br />iG L��� <br />Ag?licant Mailing Address Zip Phone <br />3.31'IVIE P6 M Vi. <br />Architect or Engineer Mailing Address Zip Phone <br />4. <br />Contractor YKam, IAW Mailing Address Zip Phone <br />5. <br />Purpose of Fill or Excavating <br />6. C(L. CO t-P cC.7ZOtvf F ti&-vi &_.i.c 1i <br />Type and Amount of Fill or Excavating <br />7. D1/2rt -C C&2TE- A- )f(.cX 40M '(b5 <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 />TOTAL FEE PAID <br />$ <br />Signature of Contractor or Authorized Agent Date <br />Signature or Owner (If Owner Contractor) 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 13 <br />Total Fee Collected $ <br />By <br />