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. <br /> r„�----.--..� �FOR CiTY USE ONLY <br /> �-�-���.,, City Of�TUnO Date Received: __ Permit# ___ <br /> P.J.Iiux 6b <br /> ,E } �' 2750 Kelley Parkway ❑[n-f fouse SAC Determina on1�F,orm(;ompleted II j <br /> �1, ,� Crystul}3ay,MN 55323 �{4(�` ,Qd ��V(l.{� G�1.���- � ��1 <br /> ',�"�q�� (952)249-4600/Fax(9�2)249-4616 Approved y(lf Required): <br /> ..,, 4 F.,,{=,i'�� <br /> CITY OF (�RO1V0—SEWER& WATER/GENERAL PERMIT <br /> (*Note:Some perniits may reyuire approval by�he Bui�ding Official andlor PubEic Works Department"j <br /> IA[.L PF,RMITS- Mav be subiect to turther review and mav not be issued when the annlicalion is received} <br /> � GENERAL INFORMATIUN _ _ __ _ <br /> 1. You may apply for utility permits by mait or in person at thc City offices. <br /> 2. Mailed in applications are subject to the postage and handling fee shown below. Permit cards will <br /> be sent by return mail withir�2 business days. <br /> 3. Yermits are not vaild until you receive a permit card. <br /> 4. Work must nat begin unless the permit card is availabie on the job site. <br /> 5. Utiliry connection permits may b�issued to licensed contractor�only. <br /> 5. Contact the Public Works Department(952-249-4600}fc�r utility stub as-built locations. <br /> DO NOT EXCAVATE l:ti ANY STREET AND DO NOT TAP ANY iVIAIN without express <br /> approval of the Public Warks llepartment. Issuance of a permit does noT grant this approval. <br /> 7. All work must be done in accordance with State Code requirements. <br /> 8. All work must be inspected befare it is covered. Call(952)249-4600,24+hour notice required. <br /> TYPE OF PERMIT <br /> (Check All That Apply) <br /> L]Residentiai(May Require Approval) ❑Commerciai(Approval Required) <br /> � New Connection []Additional Cannection [�f Re-Connection [-}Repairs ❑Disconnect <br /> ❑ Water Availability Connection For Future Hook-Up to Water <br /> Job Site/Owner Cnfarmation: <br /> Site Address: �7 � �Q-(,��S�vYI� �.+l,vC� <br /> Owner: �`�u���-�I �siJi(c�5 IVtailingAddress: I ����� l,YUC�K..f�V��1.G(,� <br /> City: .l.J�`�JZ�Y� Lip: ��.3Z. 7 <br /> Home Phone: l� ?-�7�l- �I Z� AEternate Phone: <br /> Contractor Inforrnation: '---� <br /> � <br /> Contractor: �s �.�k.1�1;��,C �t,�'L Contact Persan: �� <br /> Address: ��� ''�� �-�������'�"e N� State License#: <br /> City: ��'��'Y���� , Zip:`��.�F�/ Expiration Date: <br /> c .� <br /> Phone: �l,i 1� `��-� l�'j�-> Alternate Phone: �l Z ���'t�(�:���`�11 <br />