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<br />.. <br /> <br /> <br />Minnesota <br /> <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />2660 CIVIC CENTER DRIVE -ROSEVILLE. MINi\'ESOTA 551 13.rHOi\'E: (651) 490-2279.F:\X: (651) .I'JO-29:n <br /> <br />PAVEMENT MAlVAGEMENT PROGRA1\1 <br />SETBACK PERMIT APPLICATION <br />(City Code Section 1013.05) Permit # <br /> <br />1. <br /> <br /> <br />Name of Owner: <br /> <br />(First) <br /> <br /> <br />f:z e.. #-,' <br />(Last <br /> <br />2. <br /> <br />a <grA lJ) (')~ k n&t\ -e ~ <br />Address of Owner : (No) And Street) <br /> <br />~d\L <br />(City) <br /> <br />(V\U <br />(State) <br /> <br />5.s-11 '3 <br />(Zip) <br /> <br />3. <br /> <br />~5"1 Lf~d- -1s4~ <br />Owner Information: (Phone) <br /> <br />-:AJIA <br />(Pax) <br /> <br />~e.+ti~5@)P-:D(\\t't\~ 'CDVf <br />(I-Mail) <br /> <br />4. <br /> <br />Applicant (if different):(Name) <br /> <br />(Address) <br /> <br />(Phone) <br /> <br />5. <br /> <br />Street Address of Property Involved: <br /> <br />6. <br /> <br />a. Present Designation of Land: <br />b, Present Use of Property: <br /> <br />B <br />B <br /> <br />c. Zoning of Property: B-1 <br />d. Camp. Plan of Property: LOB <br /> <br />~tJ.~ <br /> <br />Signature <br /> <br />1/5 / J qCj Cj <br /> <br />. <br />Date of Application Submission <br /> <br />B: <br />Title: ~ I <br />D.R.C. Review Date: <br /> <br /> <br />NOT APPROVED <br /> <br />Date: <br /> <br />Q:\Plannmg Commission\Other Docu ments\P.'\ VEI\IE...'" ~'1A:\AGEME:-''T PER..\lIT.doC' <br /> <br />t.--,JqO) <br />v\-j <br />