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� � <br /> . <br /> laS, a-r7 <br /> �� �� FOR CITY USE ONL�� <br /> �Z-��/�� Citv of Oi'000 Date Recei��ed: Permit# �� � <br /> P.O.Box 66 <br /> � 2750 Kelley Pulatiay ❑In-House SAC Detcrmwat�on Fonn Compicted <br /> E , : Crystal Bay,vfN 553�3 <br /> "��; �:{''� ��, (95�)249-4600 r Fax(952)?49-46I6 Ap}noced By(If Required): <br /> "� :,,�,. <br /> CTTY OF OROn'0-SEWER& WATER/GENERAL PERMIT (�� �2' ��� <br /> ("Note:Some per�nits may require approeal Uy dio Build�n$Offiaal andror Public�Vorks Department") <br /> (.aLL PERIIITS- 1lav be subiect to furthpr receeN•and mav not be issued�vben the analicatiou is receivedl <br /> GENERAL INFORMATION <br /> ' 1. You inay apply for utility pemiits by inail or in person at the City offices. <br /> 2. Mailed ui applications are subject to the postage and handling fee shown below. Pennit cards will <br /> be sent by rehirn tneil within 2 business days. <br /> 3. Perinits aee uot vAlid uutit you receive a permit card. <br /> 4. Work must not begui wiless d�e pennit card is acailable on tlie job site. <br /> 5. Utility coiuiection pennits may be issued to licensed contractors only. <br /> 6. Contact the Public Works Department(952-249-4600)for utility shib as-built locations. <br /> DO NOT EXCAVATE IN Al�'Y STREET A.ND DO NOT TAP Al�Y MAIiV'tir-ithout express <br /> appro�•al of the Public V4'ocks Depaitwent. Issuance of a permit does not grant this approval. <br /> 7. A!1��ork must be done in accordance witli State Code requirements. <br /> 8. All��ork must be uispected before it is covered. Call(952)249-4600,24+hour notice required. <br /> TYPE OF PERMIT <br /> Check All Tliat A 1 <br /> (�Residential(May Require Approval) ❑ Cominercial(Approval Required) <br /> �New Cotmection ❑Additionai Connection ❑Re-Coimection ❑Repau�s ❑Discoiuiect <br /> ❑ Water At-ailability Conuection For Future Hook-Up to Water <br /> Job Site/Owuer Information: <br /> Site Address: _ �bo1 Cj �Q�'G�(�Q �y�, <br /> Ov�mer:��r� I�S Mailing Address: <br /> City: Zip: <br /> Home Phone: Alternate Phone: <br /> Contractor IufoiYnation: <br /> � `�.�--rsn� <br /> Contractor: �-1� Q{�ld. Contact Person: 1 � � <br /> Yhc��hry c. <br /> Address: q�(�p �«�yyy��q, �/��C, State License#: <br /> City: ��a;(,VLk-- Zip:5�y� Expu•ation Date: <br /> Phoue: �3��{�3-bq�g AlteiYiate Plione: (o�a.-6�5 -�j�7 <br />