2009-00880 - sewer disconnect - Laserfiche WebLink

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12/07/2009 10:15 FAX 1�001/002 . FOR�7`�—SE ONLY ir '"�'`" Clty of Orono Date Received:/ O�ermit t1�60 -- � .�� P.O.Box 66 ''�•" ` 2�50 Kelle �, �{G;�,;,, �,; y Parkway ❑In-House SAC Determination Form Com leted I '41� `{y�'�y`4, +�!', Crystal Bay,MN 55323 p `�\+'°`�,�� i� (9i2)249-4600 Approved By(If Required): __:..•f' CITY OF ORONO-SEWER& WATER/ GENERAL PERMIT , "Note:Some permi[s may require approval by the Building Official and/or Public Works Department*) ERVIITS- a e sub'ect f u er re few a d no e iss when t e a icatio 's iv d) GENE L INFORMATION ]. Y u may apply for utility permits by mail or in person at the City offices. 2, ']ed in app]ications are subject to the postage and handling fee shown below. Permit cards will I be ent by return mail within 2 business days, 3. Pe mits are not valid until you receive a permit card. 4. VV rk must not begin unless the permit card is available on the job site. 5. U ity connection permits may be issued to licensed contractors only. 6. Coptact the Pubiic Works Deparhnent(952-249-4600)for utility stub as-built iocations. � DC�NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MA,IN without express approval of the Public Works Department. Issuance of a permit does not grant this approval. i 7, All work must be done in accordance with State Code requirements. 8. A!1 work must be inspected before it is covered, Call(952)249-4600,24+hour notice required. � TYPE OF PERMIT i Check All That A 1 � �Residential(May Require Approva[) ❑ Commercial(Approval Required) j ❑ New Connection ❑Additional Connection ❑Re-Connection ❑ Repairs �Disconnect ❑ Water Availability Connection For Future Hook-Up to Water � Job Site/Owner Information: Site Address: 17`�� Coac�rl;y Owner: }C��}a ��,.I��► Mailing Address: S-n<- CitY� ��c"'0 Zip: Home Phone: q52-�I'7—55'�o. Alternate Phone: c�I Z•Z6�-�7 0 ; Contractor Information: I Contractor: yr �� Contact Person: �,i,� Address: ��-�y00 �� { State License#: �I City: �,U''�''l5 Zip: Expiration Date: ' Ph ne: � iz - �77-U-5�� AlternatePhone;