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HQ 5329(9'.Yd) PERMIT NUMBER <br /> HENNEPIN COUNTY <br /> ENTRANCE Transportation Department <br /> PERMIT FEES Planning Division <br /> PRIVATE; 1600 Prairie Drive <br /> RESIDENTIAL $50.00 Medina, Minnesota 55340 <br /> TEMPORARY $100.00 <br /> COMMERCIAL/ APPLICATION FOR DRIVEWAY OR STREET ENTRANCE PERMIT <br /> STREET $200.00 (READ: "General Requirements" on the Reverse Side) <br /> NAME OF APPLICANT TELEPHONE PAGER FAX <br /> MAIL ADDRESS CITY STATE ZIP CODE <br /> NAME OF PROPERTY OWNER STREET ADDRESS CITY STATE ZIP CODE <br /> CONTRACTOR PERFORMING WORK(IF KNOWN) STREET ADDRESS CITY STATE ZIP CODE <br /> 1. <br /> 2. APPLICATION IS HEREBY MADE FOR PERMISSION TO CONSTRUCT AND THEREAFTER MAINTAIN ❑ DRIVEWAY(S) ❑ PUBLIC <br /> STREETS <br /> COMME <br /> 3. BUILDING TO BE CONSTRUCTED: ElNO ❑ YES ❑ RESIDENCE ❑ SPECIFY TIYPE) <br /> 4. DRIVEWAY OR STREET WILL BE: ElTEMPORARY ❑ PERMANENT DATE PROPOSED <br /> ENTRANCE WILL BE NEEDED <br /> 5. IS THE PROPERTY: ❑ PLATTED ❑ UNPLATTED NUMBER OF PRESENT DRIVEWAYS <br /> OR OTHER ENTRANCES TO PROPERTY <br /> CITY PERMIT NUMBER <br /> 6. BUILDING PERMIT ACQUIRED: F] NO F] YES <br /> 7. TYPE OF PROPOSED ENTRANCE SURFACE: [—] BITUMINOUS ❑ CONCRETE ❑ ROCK [—] OTHER <br /> LOCATION-STREET ADDRESS COUNTY ROAD CITY <br /> 8. <br /> LOCATION-RURAL ROAD OR STREET <br /> 9. ON RURAL ROAD MILES D 0 D OF <br /> DATE PRINTED NAME APPLICANT'S SIGNATURE <br /> TO HELP THE INSPECTOR, PLACE A STAKE WITH A CLOTH ATTACHED, IN THE CENTER OF THE PROPOSED <br /> ENTRANCE AND HIGHER THAN ANY SURROUNDING VEGETATION. <br /> APPLICANT'S DIAGRAM (IF PLOT OR CONSTRUCTION PLAN IS NOT SUBMITTED) <br /> Complete this form and send all copies to: Hennepin County <br /> Transportation Department, Planning Division, 1600 Prairie Drive, <br /> Medina, Minnesota 55340. Phone: (763) 745-7643, FAX: (763) <br /> 478-4000.After approval,one copy will be returned to applicant. <br />