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Ci7Y OF dkONn � 6�141�U51U Oy/1b/y� 14:sb � :U1/U'I Nu:uuo <br /> CITY Qb' Q1tU�VU APPLI�ATION FOR UTILITY PEItMITti <br /> Hox bb(2750 Ke ley Parkway} SEWEWWATFR <br /> ,�ry�tal Bay, Ml� SS.i23 • <br /> . . ; <br /> SE�SAL11YEui;�AltQlY <br /> t. Ynu may epipiy for utility pecmits by muil or in per�or►rt the Ciry of'fitxs. <br /> 2. Mui�cd io(y�licntiWw are rubjn:i to thr pasti�r und handlin�fecs yhown below. Pormit cards wiU be�u►t by <br /> return ma�)1he samo Qey che application i�rec�ived <br /> 3, i�ermit�wre�aot va1W uutjl you recelve�p,ormh¢ard. <br /> 4. Wnrk m�u+t nQt b�e,�in unttlss the parmit cprd iA availaDlc on the job site. � <br /> S. Utility�cmn�otian pern�its m+�y bt issuCd to(iconsed contractorx only. <br /> a. Cuntact�hn�ublic Worky Dcpartmom(473-7337)far utiliry stub u-bujlt la:�tiwu. pp NOT EXCAVATC <br /> IN ANY S�'ItF,G7' AND UO NOT TAP ANY MAIN withuut exprsss ep�val vf ihe Public ilVurks <br /> Drpurtmrnt; J9stl311Ctl Df 0 pECtpf1(�CS IW��7�I11 tI1IS ip�'1fOYtJ. <br /> 7. A�l work rti st bo dorro in�cccwrdance with Stete Code roquiremcnt�. <br /> 8. All wurk m�st be�ct�c!bafore it is coverad, Cs11473•735�. <br /> � 24 bpur aotlp nquis�d. <br /> ' - . 32c�o at� <br /> JOH �X7 I�:ADD�SS. �1S i D E. 1Z�1� <br /> (�cup�ncy Typ�: ✓ Re�identlal Commercl�l <br /> i�iwuer'��Iu+ue: � � �i i�Y-t�h�1� PhoaeN be�. 4�� •�SG� <br /> - , ..�._ <br /> M�Uing Addreai? Ci . <br /> �'' ,?�c <br /> Cuatrxctor'� Naqte: �cr�TE72,�,G:t►�k'�u(c` Phone Nunaber: SS1-��' <br /> MAtllag Addrh►a��U� f.��.li� 1�12 • 4�� City: �-I►�c�u Tl��5�_4�� <br /> � <br /> P�YT TYPE ; ,3� <br /> Munieipal Sativer;C�qnaectiun($35.00�cr atub) � <br /> pip��i�o '4�' is�ches: mcstcrial_fSehcdulc 40 air testod; caat iron <br /> SA(:' C".harge (S 1,�AO.QU) ruu�t tic:Company �ll scwcr pernut apg�icatit�ns tuilCss pt�peid. lf not <br /> prCpafd, a sewCr e�nructiun permii will nat be isawed. <br /> � <br /> Municipal Waler�Coanectlon($35.00 per stub) s <br /> pipe size�,._ inc�►es: material cop�r; other <br /> WA7'GR ME'!'�R� �nust t�piCk�d up �nd paic�for at Ciry Hgl1. <br /> (5l8"rt�etc�s=�139.00; 3/4" mct�rs=5191.00; l" cnrtera�S247.00) <br /> Sepsratc['lumbin�Permii issuect far water mcter. <br /> 1rVater matera�»u t be set�pd�r.�led by OrQno Water Dep�rtmeat(473-735'Y)upon eompktion <br /> of n�eter ip�tAltst�oa. <br /> RFQUIRE$�rn;uimwn sctb�cks horu drainficld and soptic tanks i 7S' <br /> F.:�Q�IR�:�3;�tb�ck;tom s�v�r iine=i0' <br /> � <br /> ��HMIT F�E CALCULATION <br /> 1. Subtota) of�abc�ve p¢rmit requcstcd s 3S-�'"' <br /> 2. ,Sl,iut�Gc�� S .5p ,_ <br /> l ho State Bu�idin�Code Uiviaion Surch�C of S.SO per permit must bc <br /> a�cluded tbt +tch woll.�ewer nnd water cw�aoction permit requeytad. <br /> 3• 1��.�����(Unly mail•in applicmiions) $ , 1.50 <br /> 4. `FQ1'Ai�P�RM1'f FEE(add iincs 1-3 abov�} $ �7.0� <br /> ; <br /> i <br /> 7'h�unders�i�nCd hprcby appliey to the Gity of Cho»o for issuance af a Utility Permit,egrees to do <br /> al! wark in striat eiccordan�:C w{lh the ordinanccs of the City and the regul$t�onx of the State of <br /> Ivf��e�uta,and cer�ifics tl�t ail Matem�its mnde ot�thi9 appticetion are complete�truc aad c,prrect. <br /> ; <br /> , ��i�1�� <br /> 6ignattu�'of Appli�attt: Uate: <br /> , <br />