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C,17 C Li ,. <br /> t\--- A ,_„, <br /> 1r C A <br /> � f yOStreet Address: Mailing Address: /� Phone: 952-249-4600 -/ <br /> O 2750 Kelley Parkway P.O.Box 66 Fax: 952-249-4616 <br /> Orono, MN 55356 Crystal Bay,MN 55A3-0066 Website: www.ci.orono.mn <br /> iP ,=. �k Cyd 3a . 3t,ri4 �' ,z? <br /> qk istiot e "` :zg ° ht-of Wa Perm><t`A licatioi $ 1 7', $ <br /> Purpose for Construction: New ® Replacement n Repair❑ Maintenance 17 <br /> Facility Owner: Project#: <br /> Contractor: Se t,,o 4-- ..., L(.. C Phone #: <br /> Contact Person: 0r,,e-ki .S c LI wr b r',-- Cell Phone: ‘/z- Z Ea- 7Vo 3 <br /> Billing Address: act6! )Sri 14. /'{ Email: S.__hc-rbe,-cam & l<-c,-.,o,'i <br /> City: ,cr-,-�n <br /> State: (/r'l,I1.1 Zip: . 3 118 <br /> Permit Type: Excavation ®, Obstruction n -lel bine-t 1-11' a <br /> Construction Location: 5 Ci 4. i r-KD pc_ow s E f <br /> (Attach plan/sketch of proposed construction) <br /> Nearest Intersection: L.,i,4..e.0,1 a2. I, 5)<.it4•.r 1- .i)W. <br /> Excavation Size: Width: Length: Depth: <br /> P , Pc.nir SE-1— <br /> Excavation <br /> E.iExcavation Type: Trench 1Hole n Plow n Pneumagopher ElDriveways n Cabinet❑ Pedestal ❑ Other 0 <br /> Specify Other: Di R,EGT70,,/+41, ,otz 1"Jt& <br /> To int5-r-A-it_ T E et. d 6tp-JC,2._ /11A-/N ExTENS io,./S, <br /> Obstruction Information: <br /> List the portion of the R-O-W being obstructed: 101)C Ia.. ;.� +-u^' (et-/1 E Cy") LA)/ 1 tO k---> <br /> Obstruction Size: Width: Length: Depth: <br /> Hours of Obstruction: Start Date: at_ AM to End Date: at PM <br /> Construction Schedule: <br /> Start Date: I /S- f----7 Number of Days: S---- <br /> Weekend <br /> Weekend Dates: End Date: 5 D-o - ( --) <br /> By signing this document,I(the applicant)hereby state that the above information is correct and may be subject <br /> to change. If a change in any of the above information occurs,I(the applicant)will inform the local municipality <br /> for proper approval. Please send the completed permit application to: P.O. Box 66,Crystal Bay,MN 55323. <br /> t` Date: $ '1 = /7 <br /> Applicant Signature: <br /> / � — <br /> Municipality Signature. Date: A5444-71/72 <br /> TTA cKm Env T5 <br /> • 14 IW ' o Pe_gir‘46 C.--1--- <br /> • <br /> .i• )413P R6,1 /0 ,5PE. t,et c..4 IT oc <br />