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�..a ► r ��r c�xvivV APPLICATION FE?R i7�'II,ITY PERMITS <br /> � Boz bb (275() Keitcy P�rkw�y) SEWEI�IWATER <br /> Cryatal Hay, MN SS3�3 <br /> GF�IyEftw�, INFo,{� •T(ON <br /> 1. You�nay apply for utility perm its by mai]car in parson at the City offices, <br /> Z. Mailed 'rn applicutinns are subjcct W thc poatngII y�nd hatldling fccs shown beiow. Fbrmit rards wt11 be sent E�y <br /> rcturn mail the same day tho�pplication ia rtc�ived. <br /> 3. Permlts arr not vaUd untl!you rrccivo a permit cArd. <br /> a. Work musi not bcgin unlesa the permlt c.arti is ave'ilablc on thc job site. <br /> S. Utility tonnoction permi[6 may be issuecl ta iicensed cnnrractvrs only, <br /> 6. Cbnr�ct th�I'ublic Works Dcpartmant(473-7337)for utility acub as-built locations. DU NO"I'�XCAVAT'F. <br /> IN AN�' S7'REF7 ANL' DU Nt�T TA}� ANY MAfN without express approval of tt�c Public worka <br /> Ucpnrtrncnt. Issuance of n porrnii does�ot gr�nt thu approval. <br /> 7. Ali work must bo donc ir accortlance with Staic Codc rcquiromcnts. <br /> $• A�l WDCI�iT1U3t bC I113p6CC0d�Ct�TC ii i5 COV�tBCl. C&l�a��-7357. <br /> 24 hour notice reqatred. <br /> .)oss���F aUvxEss: �-�' , � (�� �L'I.C�,�r�'�I <br /> C}cCUpanc7' �'YPQ� Residentia! Camm�resial <br /> C)wue�'a N$me: I r.�'�i-� �t�l.Q �OY1�f�� Phonc Numberr: <br /> M�11in� t�ddre�s� Cjh'� ?�: <br /> Contractor's hlame: L� V r i b' Yhonc�Yura[�eri�l '�`�� � , I� <br /> Mulling At�cfress: �� _� �' J}- �.�" C�ty:�s "� � �;� <br /> PERiM�f IT TYI'� ---=_ <br /> �`G? <br /> Municip�E Sc��-cr �'onnectiot� (�35.t�(� per�tub) ��./} $ ^_ �.�� �J. <br /> pi�r �ize��__ inci�es; material��P'VC {on sand fit); cas; iron <br /> Sf�C�:hargc(�90Q,OU;mu�t a:compRn� tsil sc�vcr pctmi;t�pplications unless prcpa.id, If not prep�id, <br /> tt scwer cucin�ctior� permit wiil tiat be issued. <br /> ,.__. <br /> 5 <br /> Munietpnt Water �,onneetioo {�35.00 per stub} $ j ,j _�' <br /> pi�e si�e ` `� _ inches; material '� copper; other <br /> �'A"I�LK M�,TERS must be pieked up und peid fc�r at City�Iall. R �' --� <br /> (5!8" meiers �$139.Op; 3/4" metcrs�$191.OQ; 1" motcn-s =$247.00) <br /> S�parai� Plum�,in� Yormit issued fnr watcr rnettr. <br /> Water metcrs rr►u�t bc aet and aes�lcd�y Oronu WRter Department(473-735�upon compktion <br /> of inetcr in�tall�tioA. <br /> �tEQUIRF,D minimum sethecks from drainficld and septfc tanks= 75' <br /> R�,�UIRED sctback from sewor line�20' <br /> PERMI'T�`F,���A.:�.[�.��ATION <br /> 1. Subtotal of above permit rcquestcd �^ �J� � <br /> Z. �I�t�� $ _50 <br /> "I'ho State Hulldir�g Code Div�sio�6urchargo of S.SO par permit must be � <br /> ine3uded f�r each watl,cewer and watrr aonnection�ermlt requoated, <br /> 3. � ,� Yg&N ►��.dlin4(C?nly mail-in appliaetic�n�j $ , l SQ <br /> 4. 'I'UTAG, PERMIT FEF(add lincs 1-3 above) $ ;� � --- <br /> The undnrsigned heroby applies ta the City of Omno for issuancc of$Utility Permit,a�rees to do <br /> all wqrk in strict aceord8ncc with the ordinailces of the City �nd the rcgulQtions of the Statc of <br /> Minneaflta, �nd certifics that aIi�tat�men��tnacic c�n this applicatia;��tre eomplete, true$nd canect. <br /> Signature of Arplicani._ � ^ �-c �''�— . �- �/��� <br /> �- Daec: �9 ��T_'- <br />