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<br />Minnesota <br /> <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />2660 CIVIC CENTER DRIVE -ROSEVILLE, MINNESOTA 55113-PHONE: (651) 490-2279-FAX: (651) 490-2931 <br /> <br /> <br />PAVEMENT MANAGEMENT PROGRAM <br />SETBACK PERMIT APPLICATION <br />(City Code Section 1013.05) Permit # <br /> <br />1. <br /> <br />L/;e 2- <br />-Name of Owner: <br /> <br />(First) <br /> <br />(Middle) <br /> <br />Mc'~4Q~ <br />(Last) <br /> <br />.5& ./fRet/. ~4/. ..,r,j'l/", <br />(State) , (Zip) <br /> <br />2. <br /> <br />~o if?!: W. I/wA (r~ <br />Address of Owner: (No. And Street) <br /> <br />~ /t;/. <br />(City) <br /> <br />3. <br /> <br />~~ /- ~? J- - o<~ ~..r <br />Owner Information: (Phone) (Fax) <br /> <br />(E-Mail) <br /> <br />4. <br /> <br />Applicant (if different): (Name) <br /> <br />(Address) <br /> <br />(Phone) <br /> <br />5. ~ ()?~ tv. {)IJ/I..SSr; ~/(/J. <br />Street Address of Property Involved: <br /> <br />6. (PIN) Property identification number: 0 0 - 0 0 - 0 0 - 0 0 - 0 0 0 0 <br /> <br />7. <br /> <br />a. Present Designation of Land: <br />b. Present Use of Property: <br /> <br />c. Zoning of Property: <br />d. Compo Plan of Property: <br /> <br />~~~ <br /> <br />Signatu <br /> <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.R.C. Review Date: <br /> <br />Date: <br />