Laserfiche WebLink
r <br /> , � Y <br /> HC 5329 9/00 <br /> ENTRANCE HENNEPIN COUNTY R�CEIV � N�MBER <br /> PERMIT FEES Transportation Department � �� <br /> Planning Division SCP j $ 2008 ` ff` "Se "'Y' <br /> PRIVATE/ 1600 Prairie Drive <br /> SINGLE <br /> RESIDENTIAL $so.00 Medina,Minnesota 55340 i�Y: <br /> TEMPORARY $100.00 -`- <br /> COMMERCIAL/ APPLICATION FOR DRIVEWAY OR STREET ENTRANCE PERMIT <br /> STREET $Zoo.00 (READ: "General Requirements"on the Reverse Side) <br /> NAME 0 PPLICANT TELEPHONE "�,..5.�.'2�'L FAX <br /> L� L1'���;� �(�1�.v—� � — �p �'?��� � �.� <br /> MAILAD RE S CITY STATE ZIPCODE <br /> �(l.- � �.J 1�'`�� A- N �S��? <br /> NAMEOFPROPERTYOWNER , / STREETADDRESS � CITY STATE ZIPCODE <br /> ����r <br /> CONTRACTOR PERFORMING WORK(IF KNOWN) STREET ADDRESS CITY STATE ZIP CODE <br /> ,. �: � - " �2���o M�� �5�� l <br /> 2 APPLICATION IS HEREBY MADE FOR PERMISSION TO CONSTRUCT AND THEREAFTER � DRIVEWAY(S) � PUBLIC <br /> MAINTAIN STREETS <br /> 3. E:11!D!NG?0 9�CONS.TR!�CTFD: NO � YES � RESIDENCE � COMMERCIAL <br /> SFEGIrY'TYPE' <br /> 4. DR�VEWAY OR STREET WILL BE: � TEMPORARY � PERMANENT DATE PROPOSED <br /> ENTRANCE WILL BE NEEDED <br /> 5. �S THE PROPERTY: PLATTED � UNPLATTED NUMBER OF PRESENT DRIVEWAYS <br /> � OR OTHER ENTRANCES TO PROPERTY <br /> 6. BUILDING PERMIT ACQUIRED: NO � YES cin �/� // � PERMiTNurneea <br /> v �� �i <br /> 7. TYPE OF PROPOSED ENTRANCE SURFACE: � BITUMINOUS � CONCRETE � ROCK � OTHER <br /> LOCATION-STREETADDRES COUNTYROAD CIN <br /> $. �,% 5�����vr 6'� �' I�? � SI �r� �b <br /> LO ATION-RURAL � � � � ROAD OR STREEf <br /> 9' ON RURAL ROAD MILES ❑ ❑ ❑ ❑ OF <br /> DATE PRINTED NAME APP SIGNA RE <br /> I� S� (��� ����- ����S v r�' �-�. <br /> TO HELP THE INSPECTOR, PLACE STAKE WITH A CLOTH ATTACHED, IN THE ER OF THE PROPOSED <br /> ENTRANCE AND HIGHER THAN ANY SURROUNDING VEGETATION. <br /> APPLICANT'S DIAGRAM (IF SITE/CONSTRUCTION PLAN IS NOT SUBMITTED) <br /> �� <br /> S�. <br /> P�� <br /> P� <br /> � ; ` � � S�� � <br /> �;,��, ` ' � �,�'1 -�(� <br /> �,��� ; ��� �'� ��`�' �� � o�� N% <br /> � ��`�. �-��� ; ( , �� % <br /> � �,,,�� , -� t _ - <br /> '�'� ____-- � �� <br /> �� _ .____ _ . ________ _ �----___ __ _ _ ___ _�____--- _ ����''! <br /> --_- ` <br /> � ___ _ �� _ _ _ . <br /> _ _ , I � l � <br /> �i��'� C ` � � �I l <br /> �A Complete this form and send all copies to: Hennepin County <br /> �� � � Q(�� 1 }� Transportation Department, Planning Division, 1600 Prairie Drive, <br /> �'� �X O{� I �A� � l� Medina, Minnesota 55340. Phone: (612) 596-0355, FAX: (763) <br /> GO,� ,,� �,�t /`� � DV\ Q� 478�000.After approval,one copy will be returned to applicant. <br /> ��' �c� ��� ,�� `� <br /> � �� � � <br /> � ���,� <br /> L� �� �� <br />