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Building permit surcharge report Page 1 of 1 <br /> Step 4- Confirm building permit surcharge data Don't stop now,you're <br /> Confirm the information displayed.If correct,read the certification notice and provide your contact information.Then click the almost done!Just one more <br /> button Submit this report(near the bottom of the page)to send the report to the department.Click Edit to make changes. step to submit this report to the <br /> Click Cancel to quit and delete the report.An asterisk(*)indicates it's a required field. agency(online payment is <br /> optional). <br /> Quarterly Building Surcharge Report Review the report,enter your <br /> Population of jurisdiction is under 20,000 contact information and click <br /> —_- Quarter ending:September I Year:2011 "Submit this report"at the <br /> bottom of this page. <br /> Reporting Unit/Municipality County Telephone On the following page you'll be <br /> City of Orono Hennepin 952.249.4600 provided with an option to print <br /> Address City State ZIP code and save this report.You'll also <br /> 2750 Kelley Pkwy Orono MN 55356 be given instructions for mailing <br /> I Building Official Certification number Telephone a payment to the agency or <br /> Oman,Lyle Edward 1280 952.249.4625 make an online payment(if an <br /> amount is owed). <br /> Building permits based on valuation <br /> Construction value range No.of permits Total valuation Surcharge amount <br /> • <br /> 1,000,000 or less 1 $1,000,000 $500.00 <br /> 1,000,001 to 2,000,000 0 $0 $0.00 <br /> 2,000,001 to 3,000,000 0 $0 $0.00 <br /> 3,000,001 to 4,000,000 0 $0 $0.00 <br /> 4,000,001 to 5,000,000 1 $4,190,000 $1,419.00 <br /> 5,000,001 or more 1 $5,190,000 $1,509.50 <br /> Building permit charge: $3,428.50 <br /> Total surcharges: $3,428.50 <br /> Less retention: -$137.14 <br /> AdJustment/amendment: $0.00 <br /> Total payment owed to state: $3,291.38 <br /> Adiustment/amendment explanation <br /> Contact name <br /> Contact title• <br /> Date form was completed* September 12,2011 <br /> Contact e-mail address' __- _- -- - --- <br /> Confirm e-mail address• - __.. ___.. ___ ........-- ........-...--__ <br /> Contact phone•E <br /> I certify that I am authorized by the municipality/reporting unit to submit this information on its behalf,and the information contained <br /> is true,correct and complete to the best of my knowledge and belief.A person submitting a building permit surcharge report online,by <br /> completing the report,agrees to conduct the submission of the agreement electronically. <br /> https://secure.doli.state.mn.us/mnbps/review.php? 9/12/2011 <br />