Thank You for Your Submission

2. Utility Owner
4. Location
8. Applicant
10. Address
11. Phone Number
13. City
14. State
15. Zip Code
17. Contact Person
18. Phone Number
20. Email Address
22. 24-hour Contact
23. Phone Number
27. Contractor
29. Address
30. Phone Number
32. City
33. State
34. Zip Code
36. Contact Person
37. Phone Number
39. Email Address
41. 24-hour Contact
42. Phone Number
46. Facilities Information
    -- Select One --GasElectricalTelephoneCableSizeOther
47. Type of Construction
    -- Select One --TrenchAerialPlowHoleChamberBore

49. If you chose Size or Other, please enter in your information here.

50. If you chose Bore, please enter the type.

52. Start Date
53. End Date
55. ACKNOWLEDGEMENT

    By checking the box and signing below, you agree and acknowledge that 1) the Applicant/Contractor  must adhere to all Champlin Ordinances, MN State, and Federal Laws, in addition to the General Conditions which area attached to this document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree
57. Electronic Signature
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field