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~ III IIIIiilllliiilll ~ <br />Grading Permit 9io-pp~ication <br />(To be accompanied by two copies of grading plan) <br />DATE <br />PERMIT NUMBER <br />Owner <br />Address <br />Phone <br />Phone <br />SITE DATA <br />Job Location <br />Legal Description (or attach) <br />Lot Area <br />Set Backs: Front <br />Proposed land use or purpose <br />Side <br />Zoning <br />Frontage <br />- Rear <br />ACCESS DATA <br />^ Direct Frontage on Public Road <br />Road Name or <br />^ Via Private Easement to Public Road (Attach Deed) <br />^ Construction of New Driveway ^ Use Existing Driveway <br />Grading Plan (two copies attached) <br />Prepared by <br />Address <br />Topographical base prepared by <br />State license type and No. <br />Address <br />Soil Testing Firm <br />Soil Engineer - <br />Addresa <br />Engineering Geologist <br />Address <br />Earthwork quantities (cubic yards) <br />Cut On-site fill Imported fill <br />Indicate site o1 disposal of exported fill <br />Quantitles calculated by <br />P.E. license No. <br />Phone No. <br />Phone No. <br />P.E. license No. <br />Phone No. <br />Phone No. <br />Exported till <br />P.E. license No. - <br />ACKNOWLEDGEMENT: Thereby acknowledge that I have read this application and state that the information I have <br />provided is correct and I agree to comply with all relevant codes and regulations of Boulder County which regulate <br />grading. Consent is hereby given to Boulder County, its officers, agents, and employees to enter upon the land for the <br />purpose of such inspections, investigations, or corrective action as the Chief Building Inspector of Boulder County <br />deems necessary. <br />Contractor <br />Address _ <br />Signature <br />