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� <br />��� � <br />STREET DISRV PTION <br />Permit A��lication <br />City of Elk River <br />Building Sa fety Division <br />13065 Orono Parkway NW . Elk River, MN 55330 <br />763.635.1060 . E-mail: Building�a ElkRiverMN.gov <br />Construction Type: ❑ New ❑ Repair ❑ Other <br />The Applicant Is: ❑ Utility Company ❑ Sub-Contractor ❑ Other <br />Utility Company: <br />Business Name Phone <br />Address City <br />Contact Name Contact Phone <br />Email <br />Sub-Contractor: <br />Business Name <br />Addiess <br />Phone <br />Email <br />Cit�r <br />Cell <br />Date: <br />Office Use Onlv <br />Notes ❑ - Scan <br />Permit Total: <br />� <br />Permit #• <br />State Zip <br />GSOC Registiation # <br />State Zip <br />Payment Options: <br />� Call me for credit card payment (If different than above, please note: Phone: <br />� Send Check (Please make checks payable to the Cit�r of Elk River� <br />❑ Pay in person via Credit Card, Check, ar Cash <br />Receipt of Permit Options: <br />� Email permit (If different than above, please note: Email : � <br />� Pick up in person (All permits with plans needs to be picked up� <br />"�!»�_F���Z•7'uI�A���•��:1�:��1�7�•7y_\»AC�1_r�C•7`►� <br />Office Use Onlv <br />�PProved U��: Date: Email �pp. & Streets � Log � Lasertiche � Org. to FiLe 1llaishal � <br />Called ❑ oi L/l-7 ❑ Date: Int. Lastb7odified 01/2018 <br />