Street Use Application - City Of Lakes
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1RESET FORM
Development Review
Office Use Only
Customer Service Center
th
250 South 4
Street – Room 300
Routing#__________________
T#_________________
Minneapolis, MN 55415 – 1316
Office
612-673-3000 or 311
Amount$__________________ Permit#__________________
Fax
612-370-1416
TTY
612-673-2157
Development Coordinator _____________________________
Signature
Date
STREET USE
APPLICATION
JOB ADDRESS (PLEASE INCLUDE BLDG.#, STREET NAME & DIRECTION & BLDG NAME IF KNOWN)
OWNER / OCCUPANT NAME:
OWNER / OCCUPANT PHONE:
NUMBER OF DAYS *
CHECK
ONE
30 Days
60 Days
90 Days
* The number of days begins when the permit is issued.
I certify that all information provided in this application form and any other information provided by me in support of this application is true
and accurate to the best of my knowledge. I certify that I will comply with all applicable State and local laws and regulations in performing
the work for which this permit is issued, and that I possess all contractor and personal licenses and certificates of competency, if any, that
are required for lawful performance of the work described in this permit. I understand that the issuance of this permit does not imply or
authorize the granting of any such license or certificate of competency, nor the issuance of any business license or professional license.
.
Homeowners shall not hire unlicensed persons to perform work under any building, electrical, mechanical, or plumbing permit
SIGNATURE:________________________________________________ DATE:________________
COMPANY NAME:
CONTRACTOR LICENSE #:
COMPANY ADDRESS:
CONTACT PERSON:
CITY:
STATE:
ZIP CODE:
CONTACT PHONE #:
EMAIL:
MAKE CHECKS PAYABLE TO: MINNEAPOLIS FINANCE DEPARTMENT, OR CHARGE TO
ALL MAJOR CRE DIT
CARDS ACCE PTED
CVV#
ACCOUNT#
EXP DATE: M o____Yr ____
FOR PUBLIC WORKS DEPARTMENT USE ONLY
PW TRAFFIC ENGINEER APPROVAL_______________________________________ CONTACTED BY ___________________________ DATE_____________
Version 11.1.15
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