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et Address: Mailing Address: Phone: 952-249-4600
<br /> �O.Aj ) Kelley Parkway P.O. Box 66 Fax: 952-249-4616
<br /> O 10, MN 55356 Crystal Bay, MN 55323-0066 Website: www.ci.orono.mn
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<br /> Purpose for Construction: New ❑ Replacement ❑ Repair ❑
<br /> Maintenance n
<br /> Facility Owner: A?: [a'-fl/h Project#:
<br /> Contractor: P),,,in ba,,.. 77,k.ce.r6 Phone#: (-4 <2 - 'S CA, -13111
<br /> Contact Person: C.v.,c_ Landskvo.n Cell Phone:
<br /> Billing Address: l ist t 1----;.--v,t 'p,• Email: -.luhcAs\-rom ' �a,„lwo./4,,,,Q,COn
<br /> City: /4'i i n rIC -0 ke..
<br /> State: Mu Zip: 553 L(
<br /> Permit Type: Excavation Obstruction n
<br /> Construction Location: 3c105- eask-lukc.. 5r. OVor)o
<br /> (Attach plan/sketch of proposed construction)
<br /> Nearest Intersection: C.t-c.,k, SF s 13, tsic. FId
<br /> Excavation Size: Width: Length: Depth:
<br /> Excavation Type: Trench n Hole n Plow ❑ Pneumagopher n
<br /> Driveways — Cabinet Pedestal n Other
<br /> Specify Other:
<br /> Obstruction Information:
<br /> List the portion of the R-O-W being obstructed: E 1,3-c- S.- (14`"
<br /> Obstruction Size: Width: 1 7 Length: Depth:
<br /> Hours of Obstruction: Start Date: c' at 8 AM to End Date: io/L ata- y PM
<br /> /0-2
<br /> Construction Schedule:
<br /> /al2... Days:Number of
<br /> Start Date:
<br /> Weekend Dates: -G' End Date: /q/2-
<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 com I •ted permit application to: P.O. Box 66,Crystal Bay,MN 55323.
<br /> Applicant Signature: Date: V/ :`7
<br /> Municipality Signature: Date: 2 5,-/ !
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