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<br /> <br />( , <br />\' ()~ ; <br />Y..., \ 1Cj: <br />.---:1- """)" i <br />~<..J ' . ~,;' ~'-" <br />I(',O~~'I <br />(J~V . <br /> <br /> <br />Minnesota <br /> <br />COMi\.JUNITY DEVELOPME:\IT DEPAR'L\IE:\IT <br />2660 CIVIC CE~TER DRIVE -ROSEVILLE, ,\II.\~ESOT;\ 5,') 113-PHO~E: (651) -IYO-:!279.F;\X: fe,5 I} -190-~'n I <br /> <br />PAVEMENTMillVAGEMENTPROG~W <br />SETBACK PERMIT APPLICATION <br />(City Code Section 1013.05) Permit # <br /> <br />1. <br /> <br />iG~! L/A,l1 <br />Name of Owner: <br /> <br />~&&/Z <br />(First) <br /> <br />~ fI./;v0 ;JC:/Id /J1 <br />(,\fiddle) <br />/(orc;41lE AlJK! <br />(Cily) (Slale) <br /> <br />(List) <br /> <br />2. <br /> <br />;( 70S //?1 f(/L;',/ ST <br />Address of Owner: (No. And SIred) <br /> <br />,')5/ / '5 <br />( /ip) <br /> <br />:-:. <br /> <br />/;.5"/- f <JL/~~h2h <br />Owner Information: (Phone) <br /> <br />(Fax) <br /> <br />(I:-,\/ai/ ) <br /> <br />4. <br /> <br />Applicant (if different):(Name) <br /> <br />(\ddre:,s) <br /> <br />(1'}WI1l' ) <br /> <br />5. <br /> <br />Street Address of Property 1IJ\'olved: <br /> <br />6. <br /> <br />a. Present Designation of Land: <br />b. Present Use of Property: <br /> <br />H <br />H <br /> <br />c. Zoning of Property: H-l <br />d. Compo Plan of Property: LDH <br /> <br />~~~^;(~' ~ <br />'/. /1 / I.~/ /// ~ <br />tV &~ I>~Y . l 6/<K-?~' ~ <br />Signature <br />3-- 5cJ '- 11 <br />Date of Application Submission <br /> <br />APPROVED <br /> <br />NOT APPROVED <br /> <br />B: <br />Title: <br />D.R.C. Review Date: <br /> <br />Date: <br /> <br />B: <br />Title: <br />D.H.C. Heview Date: <br /> <br />Date: <br /> <br />Q:\Planmng CommlSSlon\Other DOCII mE'nt~\PA \'F..\IF_'\T ~1A.\A( ;E~E:\T PEft\IILdo(' <br /> <br />\)..0\..0\ <br />~.) <br />