2003-Henn. Co. driveway permit - Laserfiche WebLink

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HC 5329(9/00) PERMIT NUMBER HENNEPIN COUNTY �� ENTRANCE Transportation Department PERMIT FEES Planning Division PRIVATE/ 1600 Prairie Drive RESIDENTIAL $50.00 Medina, Minnesota 55340 TEMPORARY $100.00 COMMERCIAU APPLICAT/ON FOR DRIVEWAY OR STREET ENTRANCE PERMIT STREET $200.00 (READ: "General Requirements" on the Reverse Side) NAME OFAPPLICANT TELEPHONE PAGER FAX �. � 1�-��j'1�'� �� •-�S�._ �.3�!�'-�/,� MAII DRE CITY STATE ZIP CO � s z3S ��Gc- ��i.� ��,,. s� � NAME OF PROPERTY OWNER STREET ADDRES CITY STATE ZIP CODE ' �`1-c- S��iU,f�i�. lv/��/��/�'1� � y��'v�-�� /� ,ss.��/, CONTRACTO PERFORMING WORK(IF KNOWN) STREET ADDRESS CITY STATE ZIP CODE �. 2. APPLICATION IS HEREBY MADE FOR PERMISSION TO CONSTRUCT AND THEREAFTER MAINTAIN DRIVEWAY(S) � PUBLIC STREETS 3. BUILDING TO BE CONSTRUCTED: NO ❑ YES ❑ RESIDENCE ❑ SPEC FY TIYPE) 4. DRIVEWAY OR STREET WILL BE: ❑ TEMPORARY PERMANENT DATE PROPOSED � /�` �� ENTRANCE WILL BE NEEDED ( 5. IS THE PROPERTY: �PLATTED ❑ UNPLATTED NUMBER OF PRESENT DRIVEWAYS OR OTHER ENTRANCES TO PROPERTY CITY PERMIT NUMBER 6. BUILDING PERMIT ACQUIRED: ❑ NO � YES ��j , 7. TYPE OF PROPOSED ENTRANCE SURFACE: ❑ BITUMINOUS ❑ CONCRETE ROCK � OTHER LOCATION-STREE RESS COUNTY ROAD CI s. �l c� / //�r�� , ��' l7a LOCATION-RURAL ROAD OR STREET 9' ON RURAL ROAD MILES ❑N �S ❑E W❑ OF DATE PRINTED NAME APPLICANT'S SIGN T iR�- _ _.._______ �1�-- �� Y�-,� ��,�� TO HELP THE INSPECTOR, PLACE A STAKE WITH A CLOTH ATTACHED, IN THE CE ER OF THE PROPOSED ENTRANCE AND HIGHER THAN ANY SURROUNDING VEGETATION. APPLICANT'S DIAGRAM (IF PLOT OR CONSTRUCTION PLAN IS NOT SUBMITTED) Complete this form and send all copies to: Hennepin County Transportation Department, Planning Division, 1600 Prairie Drive, Medina, Minnesota 55340. Phone: (763) 745-7643, FAX: (763) 478-4000.After approval,one copy will be returned to applicant.