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4� <br /> FOR CrrY USE ONLY <br /> City of Orono Date Received: Permit# <br /> P.O.Box 66 <br /> Y�► 2750 Kelley Parkway ❑In-House SAC Determination Form Completed <br /> \\\ I Crystal Bay,MN 55323 <br /> (952)249-4600 J Fax(952)249-4616 Approved By(If Required): <br /> CITY OF ORONO—SEWER& WATER/GENERAL PERMIT <br /> (*Note:Some permits may require approval by the Building Official and/or Public Works Department•) <br /> (ALL PERMITS- May be subject to further review and may not be issued when the auolication is receivedl <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 /> S. All work must be inspected before it is covered. Call(952)2494600,24+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 ❑ Disconnect <br /> ❑ Water Availability Connection For Future Hook-Up to Water <br /> Job Site/Owner Information: <br /> Site Address: c�3 g&') W aJe-( le tu n <br /> Owner: P��Y i c ia. > I 1 a wt VIUi K) Mailing Address: rS°e In <br /> City: („ oV1 D Zip: 03 <br /> Home Phone: '-17 3 7171 lb Alternate Phone: �c.. I " r�i 4 <br /> Contractor Information: <br /> Contractor: ''{t hUleW 1"Ium 6 Ni, Irl Contact Person: 0 Salan'W_ <br /> Address: 7LtbD O%L. J SiyeL V State License#: <br /> City: S+. Wxy f�u 4 Zip:55q2b Expiration Date: /02 31 q <br /> Q CJ <br /> Phone: 6?.�a " 1.33� V)L) Alternate Phone: bl 01 - ql& ' 0ql y <br />