Laserfiche WebLink
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 />1104 <br />Job Address �+ <br />2s-ita It I &ti .St. <br />Lot No. elk Tract <br />Legal <br />1. Oescnotion <br />Owner Mailing Address Zip <br />2. <br />Phone <br />A licant c Mailing Ad ess Zip <br />3. \ ?Gila- \e0-5 i (02 ---)40^ S-- kt..cWO.- <br />Phone <br />aqy -000 <br />Architect or Engineer Mailing Address Lp <br />4. <br />Phone <br />CogRgctor Mailing Address Zip <br />5. k a L(o T. SeiAS <br />Phone <br />Purpose of Fill or Excavating <br />6. Yp ft\t wind ,EVt , 0.wa. <br />Type and Amount of Fill or Excavating ,Ir f <br />7 �, too - Si Coo ,a-L% - (1CV(- (title <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 />/////,/(1, (/ %� /n //J,r�,,�, ,I <br />�..�1,-./AYh�•1 / ! 0.2 weQ/ <br />Permit Fee <br />R -101 <br />-32270 <br />$ <br />State Surcharge <br />G- 101 <br />-20821 <br />TOTAL FEE PAID <br />$ <br />Signature of Contractor or �gf[horized Age Date <br />Signature or Owner (If Owner Contractor) Date <br />Puck Works Director Date <br />WHEN PROPERLY VALIDATED (IN THIS SPACE) THIS IS YOUR PERMIT <br />WHITE-Inspector <br />CANARV•Customer <br />PINK-Office <br />Permit Validation Ck MO Cash <br />Total Fee Collected $ <br />Page 15 By <br />