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<br />BWSR Forms 11-25-09 Page 1 of 2 <br /> <br />I. Landowner Statement and Contractor <br />Responsibility <br />For Work in Wetlands or Public Waters <br /> <br /> <br />MN Statutes Sections 103G.2212 and 103G.241 stipulate that an agent or employee of another may not: <br />1) drain, excavate, or fill a wetland, wholly or partially; or <br />2) construct, reconstruct, remove, or make any change in any reservoir, dam, or the course, current, or cross- <br />section of any public water; <br />unless the agent or employee has obtained a signed statement from the property owner stating that any permit or <br />wetland replacement plan required for the work has been obtained, or that a permit or replacement plan is not <br />required; AND this statement is mailed to the appropriate office with jurisdiction over the wetland or public water <br />prior to initiating the work (see next page for information on where to send this notification). <br /> <br />This form is a notification only and is not an application or authorization for any activities described in it. <br /> <br />1. PROJECT INFORMATION <br />Project will affect (check all that apply): <br /> Lake, Watercourse, or Public Waters Wetland Non-Public Waters Wetland Wetland of Unknown Jurisdiction <br /> <br />Address or description of project location (attach map if necessary): <br />Legal address <br />PIDs: 3311823320005, 3311823310013 <br />County <br />Hennepin <br /> <br />Gov’t Lot(s) <br /> <br />Quarter Section(s) <br /> <br />Section(s) <br />32, 33 <br />Township(s) <br />118N <br />Range(s) <br />23W <br />Lot, Block, Subd. <br /> <br /> <br />Description of proposed work (include sketch and/or attach additional pages if needed): <br />The City of Orono is proposing to construct a new public works facility. Included in the project is a public <br />works building, parking areas, material storage areas, utilities, landscaping, and stormwater management <br />features. <br /> <br />2. LANDOWNER STATEMENT <br /> <br />I certify that, as the owner of the property listed on this form (check one): <br /> I have obtained all permits or approvals required to perform the work described above. <br /> No permits or approvals are required for this work. <br />Property Owner (Print Name) <br />City of Orono | Adam Edwards <br />Address <br />PO Box 66 <br />Orono, MN | 55323 <br />Signature <br /> <br />Date <br /> <br />Phone Number and E-mail Address (Optional) <br />952-249-4600 <br />aedwards@orono.ci.mn.us <br />16 Mar 22