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<br />Minnesota <br /> <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />2660 CIVIC CENTER DRIVE -ROSBVILLE. MINNESOTA 55113.PHONE: (651) 49o-2279-FAX: (651) 490...29:n <br /> <br /> <br />PAVEMENT MANAGEMENT PROGRAM <br />SETBACK PERMIT APPLICATION <br />(City Code'Section 1013.05) Permit # <br /> <br />1. <br /> <br /> <br />(First) <br /> <br /> <br />5 <br />(Middlc) (Last.) <br />eut / (~/11 .5--5/ / 3 <br />(St.ate) (Zip) <br /> <br /> <br />2. <br /> <br />'J <br />. ). <br /> <br />(Fax) <br /> <br />(E-Mail) <br /> <br />4. <br /> <br />Applicant (if djflerent):(Name) <br /> <br />(Address) <br /> <br />(Phon c) <br /> <br />5. <br /> <br />Street Address of Property Involved: <br /> <br />6. <br /> <br />a. Present Designation of Land: <br />h. Present Use of Property: <br /> <br />R <br />R <br /> <br />c, Zonin~ of Property: B-] <br />d. Camp. Plan of Property: LDK <br /> <br /> <br />J <br /> <br />APPROVED <br /> <br />NOT APPROVED <br /> <br />Bv: <br />Title: <br />n.R.c. Review Date: <br /> <br />Date: <br /> <br />B: <br />Title: <br />D.R.C. Review Date: <br /> <br />Dale: <br /> <br />lJoll'ianoun~ Conomu..ionIOther Docum.nt.IPA VEMENf MANAGEMENT PERMIT.doc <br /> <br />t^..ll\ <br />'7r <br /><A~ 1/ <br />