HomeMy WebLinkAbout2009-00078 - sewer repair CITY OF ORONO PERMIT NO.: 2009-000�g
1�.� 2750 KELLEY PARKWAY
ORONO, MN 55356- DATE tSSUEn: 02/24/2009
� 952 249-4600 FAX: 952 249-4616
ADDRESS : 1820 SHADYWOOD RD
PIN : 17-117-23-24-0015
LEGAL DESC : SHADY-WOOD
: LOT 000 BLOCK 000
PERMIT TYPE : SEWER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : REPAIR
NOTE: REPAIR ONLY
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
ROTO ROOTER SERVICES CO. STATE SURCHARGE SEWER&WATER 0.50
14530 27TH AVE.N. TOTAL 50.50
MINNEAPOLIS,MN 55447-
(763)519-3907
Minnesota State License#:058341
OWNER
SKJERPING,BRUCE
1820 SHADYWOOD RD
WAYZATA,MN 55391
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be performed according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances goveming this type of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is,t sible for assuring all required inspections aze .
requested in cD' ance w' the State Building Code.This permit may be
revoked at u use. /�J
' w,� � � �o�L "---�- ��1�Cc��-� � - Z ��'
A li t ermitee Si ature Date �� � �
pp � Issued By Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
l ��
� � ,�
� FOR CI'TY USE ONLY
O,¢D�O City of Ol'ono Date Received: Permit#
PA.Box 66
. 2750 Kelley Parkway ❑In-House SAC Determi�ation Form Completed
� �.�'q' : Crystal Bay,MN 55323
• ,:`o (952)249-4600 Approved By(If Required):
��w
CITY OF ORONO—SEWER&WATER/GENERAL PERMIT
(*Note:Some permits may require approval by the Building Official and/or Public Works Department t)
(ALL PERMITS- Mav be subiect to further review and mav not be�sued w6en the aoolication l�receivedl
GENERAL INFORMATION
1. You may apply for utility pennits by mail or in person at the City offices.
2. Mailed in applications aze subject to the postage and handling fee shown below. Permit cards wilt
be sent by return mail within 2 business days.
3. Permits are not vaHd unril you receive a permit card.
4. Work must not begin unless the permit cazd is available on the job site.
5. Utility connection permits may be issued to licensed contractors only.
6. Contact the Public Works Department(952-249-4600)for utility stub as-built locallons.
DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express
approval of the Public Works Department. Issuance of a permit does not grant this approval.
7. All work must be done in accordance with State Code requirements.
8. All work must be inspected before it is covered. Catl(952)249-4600,24+hour notice required.
TYPE OF PERMIT
Check All That A 1
�Residential(May Require Approval) �Commercial(Approval Required)
l�
❑New Connection ❑Additional Connection ❑Re-Connection �Repairs �Disconnect
Job Site/Owner Information:
Site Address: ��o�� ,���t;✓vc>� ��Q
Owner: �-��"t ...X1 ���p��� Mailing Address: �b�`U �a�I.t,t oo.a' /l�
City: (��''� Zip; �
Home Phone: Alternate Phone:
Contractor Informa ion:
,
Contractor: 4�' 041C1 Contact Person: �'��`� �""��
Address: 1�S3J c��� �Gt,� State License#:
SI�'f�/�7 � -
City: /Yl Zip: YYI Expiration Date: � ".�/�ff.�j
Phone: 7(�3' ��`�" .,��f�7 Alternate Phone: 71��' S�1`" .3�1/J
.
DETERMINING PERNIIT FEES
❑SAC Charge(2�9 Rate=52,000.00) $
(SAC Chatge must accompany ail sewer permit applications unless prepaid)
(Orono City Staff can determine if applicable)
(If not prepafd,a sewer connection permit will not be issued)
Sewer Connection!Disconnect/Repalr(SS0.00/Per Stub) a b �'�S � �
Pipe siu inches;material Schd 40 air tested; cast iron
❑Water Connection/Disconnect/Repair(a50.00/Per Stab) a
Pipe si�e inches;material Schd 40 air te.sted; copper
1. SUBTOTAL of Permit Requested: $
2. STAT'E SURCHARGE $ .SO
3. POSTAGE&HANDLING(Only on Mail-In Applicarions) $ 2,pp
4. TOTAL PERMYT FEE(Add Lines 1-3 Above) a ��� •' ��
ADDITIONAL INFORMATION-WATER METERS
■ WATER METERS must be picked up and paid for at Orono City Hall,these are on a s e�g�t.
■ WATER METERS must be set and sealed by Orono Water Deparlment(952)249-4600, upon
completion of ineter installatton.
The undersigned hereby applies to the City of Orono for issuance of a Utility Pernut,agrees to do
all work in strict accordance with the ordinances of the City and the regulations of the State of
Minnesota,and certifie all state ts made on this application are,true and correct.
,
�— ��---
Applicant: Date: ����/ � �
R et�orm
�',
✓