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11/?9/2011 09:53 7635193932 PAGE 01102 <br /> '1 � <br /> . ��'�` a-- � ._ ayai. H��t� <br /> a�< � a <br /> FO C U5�ONLY � <br /> ,�p�, CityofOrnuo � 17a�cRccdvctl( Pcrmit# ��._6� � <br /> P.O.Box 66 <br /> 0 ti � 275o Kdlcy PorM�nry ❑Io-Housa S� riabcm�in�tion Form Com�lce�d <br /> Cryatal 8sy,MN 553Z3 � '.J,.�. <br /> � � � � (952)7a9-d6(X) Appro�'°d B�y Rf Rcq�irod): � <br /> � CITY O�ORONO—SEVV�R& WATER/GENERAI�PE�T <br /> (�Noh:Some pe�mitv may rcquiro spprovAl try thc Bnilding OFticiol�nNor Public Works DopuRment•) <br /> fALL P�;RbQT��be�biat to liirthar revl�v sad mav�o D!18lU1�NYM t6!SDDIII'AH4A1�!�EClIYC{I� <br /> GE�RAL INFO�ATION <br /> 1. You may apply for utility permit�by mail or in.person at th�City afi�ices. <br /> 2, Mailed in applications are subj��the postAge and handling fee shown below. Pe�mit cards w'tl) <br /> be se�nt by return mail within 2 business days. <br /> 3. Permite Arc nat valid until you rcceive a permit cartl. <br /> 4. Work must not beg'tn unless the permit c.tud is available on the job siCe. <br /> 5. Utility connectian permits may be issued to iicensed contrActors only. <br /> 6. Ccmtact th�Public Wo�ks Departmcnt(95�249-4(f00�foT utillty 9tUb AS-GUilt 1pGStIOTIs. <br /> DO NOT�XCAVA'T�IN A.NY STREET AND DO I�iOT TAP ANY MAIIV witboat expt�ess <br /> approval of thc Public Works Dcpartment. Tssusncc of a permit doe.s not grant this approval. <br /> 7, AIl work must be done in acconlancc wi�t State Gode requircmcnts. . <br /> 8. A11 work must b�inspexted beffore it is cova�od. Call(952)249-4600,Z4+hoar noticc rcqnired. <br /> TYPE OF PERNII�' <br /> Ck�ec�All That A 1 . <br /> �Csidential(May Requirc A.pproval) ❑Commercial(Approval Rcquired) <br /> ❑New Connec�ion ❑A,dditiona)Cannection ❑Re-Connoction �Repairs ❑Disconr�ect <br /> ❑ Water Availability Cotmoction F'or�uture HooK-Up co Water <br /> Job 3ite./Owner Information: <br /> Site Address: � �)� I ' �� � ' 1 ���"' <br /> Owner_����� � J��'►Cr1� Mailing Address: �W�c <br /> City: 0l�0�� Zip: ,�,L'��� � <br /> Home Phone: ��- �('Sv�1 Alt�rnate Phane: <br /> Cont�ractor Information: <br /> .. <br /> Contractar: �,,,,' Contact Person: <br /> Address: I y53� 011�=��• State License#: <br /> City: Zip: �w Expiration Date: Io1��}I I <br /> Phone: (¢ "S1�►' �Id� Alternate Phvne: ���'ap�*'-�a'a� <br />