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r � <br /> Street Address: Mailing Address: Phone: 952-249-4600 <br /> 2750 Kelley Parkway P.O.Box 66 Fax: 952-249-4616 <br /> Orono,MN 55356 Crystal Bay,MN 55323-0066 Website: www.ci.orono.mn <br /> A <br /> �lgkEstio ' Right-of-Way�Permit A lication �' <br /> Purpose for Construction: New Z Replacement❑ Repair❑ Maintenance ❑ <br /> Facility Owner: Project#: 2 pl(a- 06 13 <br /> Contractor: Phone#: <br /> Contact Person: Cell Phone: 952) 4/71-"!a,56- <br /> Billing Address: 2 D Cqz D 13s_. CbL 2o Email: 12�zte /M S " <br /> City: (r)a-0^)0 <br /> State: /vlAf Zip: 4532/ <br /> Permit Type: Excavation [� Obstruction — r:,�ia�NI�JG� J*LL— "v <br /> Construction Location: 6,oe' our a q-GN 'Zo 6 S'40'm A e G <br /> (Attach plan/sketch of proposed construction) <br /> Nearest Intersection: od-n - 's M044-hk w s <br /> �4 <br /> Excavation Size: Width: a r— Length: QD,,�--7- 3 Fi <br /> Excavation Type: Trench❑ Hole ❑ Plow❑ Pneumagopher❑ <br /> Driveways❑ Cabinet❑ Pedestal❑ Other <br /> Specify Other: c_j.--� L- <br /> Obstruction Information: <br /> List the portion of the R-O-W being obstructed: S HO L-J£a2 <br /> Obstruction Size: Width: ,Z F-r- Length: 9y ,--T- <br /> Hours of Obstruction: Start Date: at AM to End Date: at PM <br /> T:��?-mAWt^/r <br /> Construction Schedule: <br /> Start Date: Number of Days: <br /> Weekend Dates: End Date: <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 /> Applicant Signature: <br /> t <br /> Date: 1U - 2�-16 <br /> Municipality Signatu Date: T/(o <br /> As gull-'- 3U't v'CV Ib 8-* 4"e'o Q PpeJ Co.A,04.x-r7 u'--� <br /> 6400 L-af-R, AZA- v TD AsHo94-T' st-oPe R�aK i=2v� <br /> A5R,'A4LT Foti- <br />