HomeMy WebLinkAbout2009-00326 - sewer/water disconnect CITY OF ORONO PERMIT NO.: 2009-00326
� h 2750 KELLEY PARKWAY
ORONO, MN 55356- DATE IssuEn: 06/17/2009
952 249-4600 FAX: 952 249-4616
ADDRESS : 2100 SHADYWOOD RD
PIN : 17-117-23-31-0041
LEGAL DESC : WILEYS PARK LAKE MTKA
: LOT 030 BLOCK 001
PERMIT TYPE : SEWER&WATER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DISCONNECTION
NOTE:
WATER AND SEWER DISCONNECT.
APPLICANT
SEWER CONNECT/DISCONNECT/REPAIR 50.00
WESTONKA SEWER& WATER WATER CONNECT/DISCONNECT/REPAIR 50.00
650]CO.RD 15
MOUND, MN 55364 STATE SURCHARGE SEWER&WATER 0.50
(952)472-4959 TOTAL 100.50
Minnesota State License#: 58019PM
OWNER
MARHULA, DAREN
2100 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 governing this type of work
shall be compied wi[h 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 responsible for assuring all required inspections are
requested in conf ance with e Building Code.This permit may be
revoked at any ti for dge'$ se ;
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Applicant ermitee Signature Date Iss e By ignature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
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� FOR CITY USE ONLY
�' �0� Clty of�t'On0 Date Received: Permit#
O , O P.O.Box 66
�ti�,,, 2750 Kelley Parkway ❑In-House SAC Determination Fonn Completed
a �'��'�r- Crystal Bay,MN 55323
�������o� (952)249-4600 Approved By(If Required):
CITY OF ORONO—SEWER & WATER/ GENERAL PERMIT
(*Note:Some permits may require approval by the Building Official and/or Public Works Department*)
(ALL PERMITS- Mav be subiect to further review and mav not be issued when the aoplication is received)
GENERAL INFORMATION
1. You may apply for utility pernuts by mail or in person at the City offices.
2. Mailed in applications are subject to the postage and handling fee shown below. Permit cards will
be sent by return mail within 2 business days.
3. Permits are not valid until you receive a permit card.
4. Wark must not begin unless the permit card 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 locations.
DO NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express
approval of the Public Works Department. Issuance of a pernut does not grant this approval.
7. All wark must be done in accordance with State Code requirements.
8. All work must be inspected before it is covered. Call(952)249-4600, 24+hour notice required.
TYPE OF PERMIT
(Check All That Apply)
�esidential(May Require Approval) ❑ Commercial(Approval Required)
❑ New Connection ❑Additional Connection ❑ Re-Connecrion ❑Repairs °�'Disconnect
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Job Site/ Owner Information:
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Site Address: � U +� s � '
Owner: Mailing Address:
City: Zip:
Home Phone: Alternate Phone:
Contractor Information:
Contractor: � ,��S�p�t ��4 ��� Contact Person: �F�v.�, C�a� ��
Address: G,�O� � ,��. (� State License#: ��oY��^'/
City: (�.� � Zip:���Expiration Date: l � ���-�9
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Phone: ( � � - 'j� Alternate Phone: ����� 7�f�- S �� �
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, DETERMINING PERMIT FEES
❑ SAC Charge(2009 Rate=$2,000.00) $
(SAC Charge must accompany all sewer permit applications unless prepaid)
(Orono City Staff can determine if applicable)
(If not prepaid,a sewer connection permit will not be issued)
�] Sewer Connection/Disconnect/Repair($50.00/Per Stub) $
� � Pipe size inches;material Schd 40 air tested; cast iron
�ater Connection/Disconnect/Repair($50.00/Per Stub) $
Pipe size inches;material Schd 40 air tested; copper
1. SUBTOTAL of Permit Requested: $
2. STATE SURCHARGE $ .50
3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $
ADDITIONAL 1NFORMATION—WATER METERS
■ WATER METERS must be picked up and paid for at Orono City Hall,these are on a separate permit.
■ WATER METERS must be set and sealed by Orono Water Department (952) 249-4600, upon
completion of ineter installation.
The undersigned hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do
all wark in strict accordance with the ordinances of the City and the regulations of the State of
Minnesota, and certifies that all statements ir�ad���o is�pplication are, true and correct.
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Applicant: �����Date: �