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I � <br /> -��`0�� City of Orano rak "►T ' �i� Se o�I.t' <br /> P.O.I3ox b6 Date Received:�- /- crmit# /5- 7� <br /> � � � 27�0 Kellcy P�rkway <br /> � � C'rvstal�ay,�QN i5323 ❑1n-House SAC Determmation Form Compieted <br /> ';��,ti`��� (9S2)249-4b00/Fax(952)249-4G 16 A <br /> �'"f`'- � pproved BY(Ii°Itequired): <br /> C1TY pF ORONO—SEWER& WAT�R t GENERAL PERMIT <br /> (*'�ote Some permits may reyu�re approvai by the Building C)tficiat and/or Public Works Department*) <br /> (A1.L PF.R'4iITS- ��ta be suhiect to further rer•iew and mav not be issued when the au t�rat�nn�s______recri,ived) <br /> GENER�L INFOEZM�TION <br /> I• You may app(y for utility pennits by ma�l or in persoo at the City offic�s. <br /> 2. Mailed in applications are subject to the postage and handling fee show�n below. Pennit cards wil! <br /> be sent by return mail within?bttsiness days. <br /> 3. Permits are not vaiid untii you receive a pern�it card. <br /> 4• �i�'ork must not begin unless the permit card is avai(ahle on the job site. <br /> 5. Utility connection permits may be issued ta Iicensed contractors onlv. <br /> 6. Contact the Public Works Depaitment{952-249-4600)for utility stub as-bt�ilt locations. <br /> DO NOT EXCAVA'TE IN AiV'y STREET A,'�f)DO NOT TAF ANY MA�IIv without express <br /> approvai af the Public Works Depart►z�ent. (ssuance c�f a pern�it does not grant this approval. <br /> 7. Atl work inust be done in accordance with State Code requirements. <br /> 8. A11 work must be inspected before it is covered. Cail (952}249-4600,24+hour notice reyuired. <br /> TYPE OF PERMIT <br /> Check All That A I <br /> �esidentia((May Require Appraval) ❑�'on�mercial(Approval Required} <br /> .,. <br /> �'�tew Connection ❑Additiv��al Connecti�n <br /> ❑Ke-Connection ❑Repairs ❑Disconnect <br /> ❑ Water Availability Coimection For Puture Hook-Up to Water <br /> Job Site I Owner Information: <br /> Site Address: � � �' � �-� r-� <br /> ���������;��, <br /> Owner: t-�'Ct,�1:..,.�r�,'�'1fl`����"� -��l 3���� Mailing . <br /> Address: �� ���%�;��t.�i��7�r,� �l�=�� <br /> , <br /> City: r"�'�'��'`��S ( �'`�✓�. Zip: �`.� �� _-�' <br /> , --,�, ; <br /> Hame Phone: �� '`�t. �—� � t "� I A lternate Yhone: <br /> Contractar lnformation: <br /> -�., .� . ... <br /> Contractor: �..=�(�-�.L�.���;��' �;-�(��t�rf�17'� Contact Person: c..,�� �S{'.tC.-��,("�C'�.�.d'"� <br /> Address: �{ r~')(�;-�--�":7C,��:;iG�t:{ �-�x i�5`��G''� State License #: <br /> City; fi�Vl `;�' ! ,� % Z.i� ���j.�`�;�E�piration Date: <br /> Phonc: ��)�� ��--�� �t'���� t Alternate Phone: �`( �,,. C��t� �---{� ��-� <br />