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„ � <br /> iC5329(9/00) <br /> ENTRANCE IiENI�EPIN COUNTI( PERMIT NUMBER <br /> PERMIT FEES Transportation Department �� <br /> PRIVATE/ Planning Division <br /> RESIDENTIAL <br /> TEMPORA �-$�oo.op.. 1600 Prairie Drive <br /> coMnnERciau � Medina, Minnesota 55340 <br /> STREET $200.00 <br /> APPLICATION FOR DRIVEWAY OR STREET ENTRANCE PERMIT <br /> . (READ: "General Requirements”on Attached Page) <br /> AME OF APPL T � TELEPHONE PAGER FAX <br /> C��. -'�. '' � 9s2�'�-�8�t — 9SZ-qvo-��z�r <br /> AILADDRESS CITY STATE ZIPCODE <br /> �o�� �`6. , �►IdD S�,lo�..� �.�� � �Z-� <br /> AME p�F�PROPERTY O NER STREET ADDRESS CITY STATE ZIP CODE <br /> ��►� ��^'�� ' �`'lO (�,�1c Or C�'c �� 5S3"I� <br /> CONTRACTOR PERFORMING WORK(IF KNOWN) STREET ADDR S CITY STATE ZIP CODE <br /> ,. (d� Ox�9 �-� �. (.n:.S��l� �,� �z�. <br /> 2 APPLICATION IS HEREBY MADE FOR PERMISSION TO CONSTRUCT AND THEREAFTER MAINTAIN lJ`t�RiVEWAY(S) ❑ Pi1BLIC STREETS <br /> 3. BUILDING TO BE CONSTRUCTED: �l0 � YES � RESIDENCE � COMMERCIAL <br /> (SPECIFY TYPE <br /> 4. DRIVEWAY OR STREET VI�iLL BE: �TEMPORARY ❑ PERMANENT DATE PROPOSED <br /> ENTRANCE WILL BE NEEDED 1��� <br /> 5. IS THE PROPERTY: �PLATTED ❑ UNPLATTED NUMBER OF PRESENT DRIVEWAYS ` <br /> OR OTHER ENTRANCES TO PROPERTY <br /> �y CITY MIT NUMBER <br /> g. BUILDINGPERMITACQUIRED: ❑ NO r51 YES „�, fyg�, <br /> 7_ TYPE OF PROPOSED ENTRANCE SURFACE: � BITUMINOUS � CONCRETE ��OCK . �OTHER <br /> LOCATION—STREET ADD ESS COU TY ROA,D,� CITY <br /> s. ��►.�ti e9S e� O� � � 1� <br /> LOCATION—RURAL ' ROAD OR STREET <br /> 9' ON RURAL ROAD_� � �?/ MILE� � OF � � �/ <br /> �ATE PRIN NAME APPLICA <br /> y-�-� � �� <br /> TO HELP THE lNSPECTOR, PLACE A STATE WITH A CLOTH ATTACHED, IN CE R OF THE PROPOSED ENTRANCE <br /> 4ND HIGHER THAN ANY SURROUNDING VEGET,4TION. � <br /> APPLICANT'S DIAGRAM (IF PLOT OR CONSTRUCTION PLAN IS NOT SUBMITTED) � <br /> ����J <br /> � <br /> � P- <br /> �f <br /> �� � <br /> A'� <br /> RECEIVED <br /> MAY O 12008 ���E � -�� <br /> BY: <br /> Complete this form and send all copies to: Hennepin County <br /> Transportation Department,Planning Division,1600 Prairie <br /> Drive, Medina,Minnesota 55340. Phone: (612)596-0355, <br /> FAX: (763)478-4000. After approval,one copy will be <br /> retumed to applicant. <br />