HomeMy WebLinkAboutROW18-000001 °ov/ I Dorno I
.4iLID0 Street Address: Mailing Address: Phone: 952-249-4600
2750 Kelley Parkway P.O.Box 66 Fax: 952-249-4616
Orono,MN 55356 Crystal Bay,MN 55323-0066 Website: www.ci.orono.mn
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Purpose for Construction: New❑ Replacement d Repair❑ Maintenance❑
Facility Owner: Project#:
Contractor: S O tii1 V it hN) 7661(11.1 Phone#: / , -�,0
Contact Person: �D Ff U(,p ,} Cell Phon-; /Z ZZ2-5,34
Billing Address: 2-3 S3 ?i i._o 4410 ;or r t Email: t[ ##i a y X ; :c•4 •Gpud
City: `DT: 'D)OL
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State: M 1J Zip: 657 ZtO
Permit Type: Excavation g Obstruction ❑
Construction Location: 3 rj(o 5- 9 6(2.1 G IL S : 0 pp 1,0 ,M N C5I3 31 i
(Attach plan/sketch of proposed construction),
Nearest Intersection: C-A9MetJ 9-1, 4 CAtx`o Po,ivi" lap
-1-01430- SF 40, S'w( -ir i )►
cgvq 1lo Excavation Size: Width: L$ S goy TLength: Z Depth: I_
22541p
Excavation Type:
Trench❑ Hole ❑ Plow❑ Pneumagopher❑
Driveways d Cabinet El Pedestal El Other❑
Specify Other:
Obstruction Information:
List the portion of the R-O-W being obstructed:
Obstruction Size: Width: Length: Depth:
Hours of Obstruction: Start Date: at AM to End Date: at PM
Construction Schedule: -�
Start Date: 'v MJ111� 14 (J N7 ,�Number of Days: 02 wags Ili 'ye.A `dc'h(3
Weekend Dates: '}C r. d Date: J 1 s-r:
(,i i Ra AZ) (ht,1 R(c-rroN S)
By signing this document,I(the applicant)hereby state that the above information is correct and may be subject
to change. If a change in any of the above information occurs,I(the applicant)will inform the local municipality
for proper approval. Please send the completed permit application to: P.O.Box 66,Crystal Bay,MN 55323.
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Applicant Signature: ieTDate: �� U
Municipality Signature: #1,t. _Cr� Date: 5,// /$