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°ov/ I Dorno I <br /> .4iLID0 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 /> � ,,: t t ``: ' <br /> Purpose for Construction: New❑ Replacement d Repair❑ Maintenance❑ <br /> Facility Owner: Project#: <br /> Contractor: S O tii1 V it hN) 7661(11.1 Phone#: / , -�,0 <br /> Contact Person: �D Ff U(,p ,} Cell Phon-; /Z ZZ2-5,34 <br /> Billing Address: 2-3 S3 ?i i._o 4410 ;or r t Email: t[ ##i a y X ; :c•4 •Gpud <br /> City: `DT: 'D)OL <br /> 1 <br /> State: M 1J Zip: 657 ZtO <br /> Permit Type: Excavation g Obstruction ❑ <br /> Construction Location: 3 rj(o 5- 9 6(2.1 G IL S : 0 pp 1,0 ,M N C5I3 31 i <br /> (Attach plan/sketch of proposed construction), <br /> Nearest Intersection: C-A9MetJ 9-1, 4 CAtx`o Po,ivi" lap <br /> -1-01430- SF 40, S'w( -ir i )► <br /> cgvq 1lo Excavation Size: Width: L$ S goy TLength: Z Depth: I_ <br /> 22541p <br /> Excavation Type: <br /> Trench❑ Hole ❑ Plow❑ Pneumagopher❑ <br /> Driveways d Cabinet El Pedestal El Other❑ <br /> Specify Other: <br /> Obstruction Information: <br /> List the portion of the R-O-W being obstructed: <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: 'v MJ111� 14 (J N7 ,�Number of Days: 02 wags Ili 'ye.A `dc'h(3 <br /> Weekend Dates: '}C r. d Date: J 1 s-r: <br /> (,i i Ra AZ) (ht,1 R(c-rroN S) <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 <br /> Applicant Signature: ieTDate: �� U <br /> Municipality Signature: #1,t. _Cr� Date: 5,// /$ <br />