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HC53�"29(9/b0 j <br /> ENTRANCE HENNEPIN COUNTY PERMIT NUMBER <br /> PERMIT FEES Transportation Department L��¢9 <br /> PRIVATE/ • ft Planning Division <br /> RESIDENTIAL $50.� �,bL�`d�'`�`�` <br /> TEMPORARY $�oo.o0 1600 Prairie Drive <br /> COMMERCIAU Medina, Minnesota 55340 <br /> STREET $200.00 <br /> APPLICATION FOR DRIVEWAY OR STREET ENTRANCE PERMIT <br /> (READ: "General Requirements"on Attached Page) <br /> NAME OF APPLICANT , P ,, TELEPHONE PAGER FAX <br /> ��., � �F ���� �� �s��-y�Z/—�'�y �- �- <br /> MAIL ADDRESS ' � � ��� CITY a STATE ZIP CODE <br /> �G�� � ( ��� c,�.�.. ��. �� �s.��2 <br /> NAM PROPERTY OWNER STREET ADDRESS CITY STATE ZIP COOE <br /> �,L��V�M � ` �� ���� / �4'Z'\ `r I 1✓ '�`V �I� �� 1F, <br /> J <br /> CONTRACTOR PERFORMING WORK(IF KNOWN) STREET ADDRES CITY STATE ZIP CODE <br /> � <br /> 1. �'j-�' ' ,�' <br /> 2 APPLICATION IS HEREBY MADE FOR PERMISSION TO CONSTRUCT AND THEREAFTER MAINTAIN I�•DRIVEWAY(S) ❑ PUBLIC STREETS <br /> 3. BUILDING TO BE CONSTRUCTED: � NO �YES � RESIDENCE � COMMERCIAL <br /> .;C �-- SPECIFYTYPE <br /> q. DRIVEWAY OR STREET WILL BE: ❑ TEMPORARY � PERMANENT DATE PROPOSED +���I � '. <br /> ENTRANCE WILL BE NEEDED I <br /> 5, IS THE PROPERTY: �-�LATTED ❑ UNPLATTED NUMBER OF PRESENT DRIVEWAYS i <br /> OR OTHER ENTRANCES TO PROPERTY I <br /> CIT R PER IT NUMBER <br /> g. BUILDING PERMIT ACQUIRED: ❑ NO �YES ��" �,1 u ��/� C1 <br /> �, TYPE OF PROPOSED ENTRANCE SURFACE: �BITUMINOUS � CONCRETE � ROCK �OTHER <br /> LOCATION—STREET ADDRESS �1COUNTY ROAD CITY <br /> 8. j !��-� � � '' ' c,a:+;!:ac� I�t H'l�:'� 1 j � �c� +'1 � <br /> LOCATION—RURAL ROAD OR STREET <br /> 9' ON RURAL ROAD MILES � � � � OF <br /> DATE P ED NAME �„ , APPLICANT' IGNATURE <br /> / � �/I <br /> 7'' � ""(�'� <:1 �i...� i C� 4 ( 5� v �i'rJ-i-�i'J AC..�C.�7 <br /> TO HELP THE INSPECTOR, PLACE A STAKE WITH A CLOTH ATTACHED, IN THE CENTER OF THE PROPOSED ENTRANCE <br /> AND HIGHER THAN ANY SURROUNDING VEGETATION. <br /> APPLICANT'S DIAGRAM (IF PLAT,SITE PLAN, OR CONSTRUCTION PLAN IS NOT SUBMITTED) <br /> , ' • - �"� �Z Ct I'r V'u LcJ ��1�'� V Ci.�le <br /> � (,` V� � 11��� '�. L� C l V k7 a.CiG ��(,y 4C.�� � <br /> � � /l/`_ <br /> � ����^l�^ �� ���.�� �4� \ u��/�� <br /> �C�r <br /> � �w�r��.�-c.r�? i'�1 c� ✓ � � <br /> c� � � <br /> � ��, ,�Lc��` <br /> K S' ��� �C� t��s2 (,�� ��,. � I1 U� <br /> �c, �c;�.� <br /> � �, ��z �, f �� ��,.�y �� ��-� , <br /> � �� _ <br /> �.r _ _ . . , _ . _ <br /> `' �nrr2'`q" � ll,;�as� <br /> � `h� , ; . .._ � . <br /> �y�1 ! ��i,L ' 1 <br /> ..N . <br /> ,�� , `� — ' Complete this form and send all copies to: Hennepin County <br /> �,�`' t Transportation Department,Planning Division, 1600 Prairie <br /> E"'" � �� �?��J'� Drive,Medina,Minnesota 55340. Phone: (612)596-0355, <br /> N'` FAX: (763)478-4000. After approval,one copy will be <br /> { iG'wE��s'� retumed to applicant. <br />