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CITY OF AUBURN DEPARTMENT OF PUBLIC WORKS <br />BUILDING DIVISION <br />I ONn CI FARING PFRMIT OPPI ICOTION <br />Rim niNC. fNVISInN PHONF- 931_3010 <br />DATE SUBMITTED PROJECT NAME APPLICATION NO. <br />OWNER: PHONE/HM PHONE/WK <br />ADDRESS CITY/ST/ZIP <br />CONTRACTOR: PHONE PHONE/PRJ <br />ADDRESS CITY/ST/ZIP <br />STATE CONTRACTOR'S DEPT. OF REVENUE INDUSTRIAL INSURANCE <br />REGISTRATION NO. SALES TAX NO. ACCOUNT NO. <br />ENGINEER: PHONE <br />ADDRESS CITY/ST/ZIP <br />SITE ADDRESS: PARCEL NO. REQUIRED: <br />LEGAL DESCRIPTION: <br />DESCRIPTION OF WORK: <br />ESTIMATE COMPLETION DATE SOIL CLASSIFICATION ENG GEOL RPT BY <br />CY <br />AREA OF CLEARING SF MAX. EXISTING SLOPE <br />DISTURB VEG MAT YES NO MAX. FINISHED SLOPE <br /># OF TREES > 6" REMOVED SOIL RPT BY PROJECT <br />VALUE <br />NOTE: <br />1) This permit does not constitute approval or compliance with the rules, regulations, or requirements of any other jurisdiction, which may <br />relate to the above project. <br />2) Check with U.S. Army Corps of Engineers for possible permit requirements. <br />3) Permits are non-transferable. <br />4) WHERE MORE THAN 20 TREES WILL BE HAULED AWAY FROM THE SITE TWO (2) COPIES OF A HAUL ROUTE PLAN SHALL BE <br />SUBMITTED FOR APPROVAL PRIOR TO ISSUANCE OF THE LAND CLEARING PERMIT. <br />I CERTIFY THAT THE INFORMATION FURNISHED BY ME IS TRUE AND CORRECT AND THAT THE APPLICABLE CITY OF AUBURN <br />REQUIREMENTS WILL BE MET. <br />OWNER/AGENT: RECEIVED <br />BY <br />NAME TITLE <br />PRINT NAME: <br />DATE: <br />REF. H:AFORMS\FB013\3-95