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APR-11-2006 15�20 FROM PUBLIC WORKS TO 99524710639 P.02i02 <br /> HC�32a�9i��) <br /> Er�rt�ANcE HENNEpEN COUNTY -P�RMiT Nunn��R <br /> PERMIT FEES TranspOrtatiorl Department tf�- � <br /> F�RIVATE/ Plannin Division <br /> RESIDEfVTIAL $.`'i0.00 g <br /> T�MPORARY $�oo.o0 1600 Prairie Drive <br /> coMr�ERciau �' Medina, Minnesota 55340 <br /> STREET $20D.OQ <br /> � APPLICATION FOR pRIVEWAY OR STREET ENTRANCE PERMl1" <br /> (READ: "General Requirements"On the Reverse Side) <br /> NAME OF APpLICAN7 �C� TELEPHONE PAGER FAX ,�,�lJ G' <br /> ���)��'�l.J ;`�'J�-� ����,� ,� \�)✓�: � t...� � 6� Z �!�'{ U C�1 S -.. C(� �-- y t � _ ✓� <br /> Mqll,ADDf:tS5 ���� - CITY STATE ZIP CODE <br /> �; �; �-�^} w�' � �T� ����� �T ���5 �,cl k n,,.,,._ ;5:�z� <br /> NAME pF PROPERTY 4WNER STRE�T AODf�ESS CITY STATE ZIP CODE <br /> � �T� 1���� ``. <br /> � tc /Y�,—,�---. <br /> CONTRAC R PERI�ORMING WORK(IF KNOWN} STREETADDR�SS CI7Y STATE 21P�CODE' �����lW�'��� '� <br /> 1. �`r ' �'J"��`�1!��� <br /> 2 APPLICATION IS HERE[3Y MADE FOR PERMISSION TO CONSTRUCT AND THEREAFTER MAINTAIN DRIVEWAY(S) ❑ PUBUC S7RE�7S <br /> 3. bUf�D(NG TO BE COti:.TRUCTEC_ ',� t�0 I� >'�,S (� RESiDEP.'.CE �I �QMMERCIAL <br /> 7�~ SPECIFY TYPE <br /> . .._._.,..._._._._..__ ..._...._.. _._---------� <br /> q, DRIVEWAY OR S7REET WII.L BE: �TEMPORARY ❑ PERMAN�NT DqT�PR01'OSED � r-y_��� �� <br /> �' ��=� 5 ENTRANCE WILL BE NEEDED - �m' <br /> 5, IS THE PROPERTY; �(PLAI7ED ❑ UNPLATTED NUMB�R OF PRESENT DRIVEWAYS / �� ��' <br /> OR OTNER ENTRANCES TO PR�PERTY ( "� �ZD, <br /> CITY �� PERMIT NUMBER � <br /> Q. BUILDING PERMIT ACQUIRED: ❑ NO � YE5 ��� �� �� `✓ � <br /> F� � � I ��� —, <br /> �, TYPE OF PROPOSED ENTRAt�lC�SURFAC�: � BI7UMItV0U5 � CONCRETE �' ROCK �OTHER <br /> LaCATION-STREET ADDRESS �� COUNTY ROA� CITY <br /> 8. 2v�; �J<,.c;;,� ��,�a�. � �r� G� I� 1� ���ud <br /> � LOCAT�ON-RURAL ROAD OR STREET "�w"`�� <br /> 9' ON RURAL ROAD MILES � � � � OF <br /> � " E <br /> pAT� PRINT�D NAME APPL! ' S TURE <br /> `�..(' d O `��' �'=�t�' r`'Z �Jn�J��`�;�.tJ �^/`� r�/i.�iL�"�'J <br /> TO H@'LP T E lNSPECTOR, PLACE A STATE WITH A CLOTH ATTACHED, I E ENrER OF rHE ROPOSED ENTRANCE <br /> AND H/GHER THAN ANY SURROUNDING VEGETATION. <br /> APPLICANT'S DIAGRAM (IF PLOT OR CONST�ti.i��'I�iV PLAN IS Pf�6��iiBnni i ) <br /> N <br /> cT�`�`��` 5 t�l��i ��-� U C� <br /> �'Q�P � � <br /> �'�� � �EG������ • <br /> � <br /> � � `' 2��6 <br /> y � �P�� � � <br /> � O��P��oN <br /> � SR�'`��p t�N��� <br /> I(-�,� �, Comple�e�h�s rorm and send aft coples�o: Hennepin County <br /> _. Transportation Department,Planning Division, 1600 Prairie <br /> Drlve,Medlna, Mlnnesoca 553A0. PhonQ_ (692)596-0355, <br /> � FAX: (763J 478-4000. After approval,one copy will be <br /> nretumed tn applicant_ <br /> � TOTAL P.02 <br />