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CITY OF MIDLAND ENGINEERING DEPARTMENT PERMIT APPLICATION Permit No. JOB ADDRESS OWNER MAIL ADDRESS ZIPCODE PHONE CONTRACTOR MAIL ADDRESS ZIPCODE PHONE SEWER PERMITS Residential Sanitary Sewer Connection, Residential ($200.00) $ Storm Sewer Connection, Residential ($200.00) $ Sanitary Sewer and Storm Sewer Combined Connection, Residential ($300.00) $ Commercial Sanitary Sewer Connection, Commercial $400.00) $ Storm Sewer Connection, Commercial ($400.00) $ Sanitary Sewer and Storm Sewer Combined Connection, Commercial ($700.00) $ RIGHT-OF-WAY PERMITS Street Cut Permit ($250.00) $ Street Cut Deposit or Right-of-Way Bond Deposit *($2.500.00) $ *Refundable upon satisfactory repair of street or completion of work Right-of-Way Activity, Describe: General/Misc Right-of-Way Permit, one permit includes but not limited to the following: ($100.00) $ Sidewalks, Curb Cuts, Paved Driveway Approaches TOTAL $ NOTICE: This permit becomes null and void if work or construction authorized is not commenced within 50 days, or if construction or work is suspended or abandoned for a period of 50 days at any time after work is commenced. I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this type of work will be complied with whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or local law regulating construction or the performance of construction. That the City of Midland is not responsible for the condition, maintenance, upkeep, or repair of the sewer lateral. It is the homeowner's responsibility to insure its proper operation and function. By the issuance of this permit, the City of Midland, in no way, represents that the lateral is in proper working condition. SIGNATURE OF CONTRACTOR OR AUTHORIZED AGENT DATE SIGNATURE OF OWNER DATE R:\Engineering Dept\Eng Sewer Permit\Permit Application Form Revised 1/1/23 SIGN SIGN