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City of Elk River <br /> 13065 Orono Parkway <br />Elk River, MN 55330 <br />Telephone: 763/441-7420 <br />Fax: 763/441-7425 <br /> <br />City Permit Number: <br /> <br />Parcel Identification Number: 75- <br /> <br />13065 Orono Parkway <br />Elk River, MN 55330 <br /> <br /> APPLICATION FOR STREET DISRUPTION/UTILITY HOOK-UP PERMITS <br /> <br />Street Disruption Permit <br /> ($100) <br /> <br />[~] Utility Hook-up Permit <br /> ($1 ,ooo) <br /> <br />Note: A separate application and Street Disruption Permit (installing main facilities) is required for each <br />quarter/quarter section. Only one Utility Hook-up Permit (connecting services to a building) is required <br />each year with monthly reporting to the c!ty of where hook-ups have occurred. <br /> <br />Applicant and/or Utility Company: <br />Address: <br /> <br />City: State: Zip: <br />Contact Person' Phone #: <br /> <br /> i <br />GSOC Registration #: Plan #: [ Project #: <br /> ~.gal Description of Street Disruption Permit (QuartedQuarter, Section, Township, Range): <br /> <br />From and To (Address/Street): <br /> <br />Sub Contractor: <br />GSOC Registration #: <br />Contact Person: <br /> <br />Phone #: <br /> <br />Note: Add additional sheets if more than one subcontractor. <br /> <br />Note: A minimum of one person trained regarding Gopher State Regulations within the last year shall be <br />at each job site while work is being performed. Proof of said training shall be submitted with permit <br />application. <br /> <br />Name of Person(s) with said training: <br /> <br />L~st l ype ot Ut,~ty: Maximum cieptn ot Installation <br /> <br />Note: Installation of utilities deeper than 48 inches is prohibited without specific city approval <br /> <br />inches <br /> <br /> Phone: 763.441.7420 <br /> Fax: 763.441.7425 <br />$: \PLANNING\FORMS\ROWFORM.DOC <br /> www. ci.elk-river, mn.us <br /> <br /> <br />