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CITY OF ROSEVILLE Fermi t <br />2660 Civic Center Drive Permit Fee <br />Roseville, MST 55113 Deposit <br />Phone 490 -2239 TOTAL <br />Receipt <br />Date <br />APPLICATION <br />EXCAVATING a, GRADING OR FILL PERMIT <br />Legal Description of Property: <br />Site Address <br />Owner ,? s <br />Name Address <br />City/State � hone <br />Fill. Contractor v s <br />Name Address <br />City/State Phone # <br />Number of Acres <br />Approximate amount of Fill <br />Type of Fill <br />City of Roseville reserves the right to cancel this permit at any <br />time due to contaminated or unauthorized type of fill. <br />011 OR 004p Ip FOR CITY USE OR__Y <br />Number of Site Flan <br />Starting Date F3.na l Completion Date <br />Type of Erosion Control required <br />Number of Inspections Required <br />