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R <br /> C USE ONLY�^ <br /> P.O.BoxCity of Orono Date Receiv 't# 0 <br /> 2750 Kelley Parkway ❑In-House SAC Determination Form Completed <br /> Crystal Bay,MN 55323 <br /> � <br /> ¢��� (952)249-4600/Fax(952)249-4616 Approved By(If Required):AFSHO <br /> CITY OF ORONO-SEWER& WATER/GENERAL PERNUT <br /> (*Note:Some permits may require approval by the Building Official and/or Public Works Department•) <br /> (ALL PE - May be sublert to further review and may not be Issued when the application Is received) <br /> GENERAL INFORMATION <br /> 1. You may apply for utility permits by mail or in person at the 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 within 2 business days. <br /> 3. Permits are not valid until you receive a permit card. <br /> 4. Work must not begin unless the permit card is available on the job site. <br /> 5. Utility connection permits may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(952-249-4600)for utility stub as-built locations. <br /> DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express <br /> approval of the Public Works Department. 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 before it is covered. Call(952)249-4600,24+hour notice required. <br /> TYPE OF PERMIT <br /> Check All That Apply) <br /> Residential(May Require Approval) ❑Commercial(Approval Required) <br /> ❑New Connection ❑Additional Connection ❑Re-Connection ❑Repairs Pq Disconnect <br /> ❑ Water Availability Connection For Future Hook-Up to Water <br /> Job Site/Owner Infonnation: <br /> Site Address: 16 to® ��r kW P d <br /> Owner: �\\\2`L 't-+C7`MC Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor Information: <br /> Contractor: IW4e.6,�e Sw G Contact Person: ��eV\ <br /> Address: Zc�S�1 W1�.��ci�� 1 L-. State License#: <br /> City: 4 AoJ W e e__ Zip:'-&3q[ Expiration Date: <br /> Phone: 7(Q3'- `�g g�0 Z Altemate Phone: �7Ce3--2 8 to 67 <br />