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Home My WebLink About2010-00396 - water & sewer disconnect � CITY OF ORONO PERMTT NO.: 2010-00396 � 2750 KELLEY PARKWAY ORONO, MN 55356- DATE ISSUEn: OS/27/2010 952 249-4600 FAX: 952 249-4616 ADDRESS : 2172 SHADYWOOD RD PIN : 17-117-23-42-0010 LEGAL DESC : WILEYS PARK LAKE MTKA : LOT 000 BLOCK 001 PERMIT TYPE : SEWER& WATER PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : DISCONNECTION NOTE: WATER&SEWER DISCONNECT APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00 AREA WIDE PLUMBING WATER CONNECT/DISCONNECT/REPAIR 50.00 9989 190TH ST. STATE SURCHARGE SEWER&WATER 0.50 SILVER LAKE,MN 55381- (952)292-5297 TOTAL 100.50 Minnesota State License#: 61937-PM OWNER DORE, STEVEN 8351 WEST 109TH STREET BLOOMINGTON, MN 55438- AGREEMENT AND SWORN STATEMENT The work for which this permit is issued shall be performed according to the approved plans and specitications,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 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 afrer work has commenced. The applicant is responsible for assuring all required inspections are requested in conforn}ance with the ate Building Code.This permit may be revo d at any tim r due cause �i l l �>�22�t-�- 5 /a 7//D Applicant Permitee Signature Date I ed By Signature Date SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. � � � �5� F CITY SE ONLY 2c��] " 0 City of Orono Date Receive oZ7 OPermit#o2D/D ^ QcJ /� � �� P.O.Box 66 O O",�:, Z�50 Kelley Parkway ❑In-House SAC Determination Form Completed [ � ��`� �� Crystal Bay,MN 55333 �''-- �x .r.o`.' (952)249-4600 Approved By([f Required): :�y�StO�y�� CITY OF ORONO—SEWER& WATER/GENERAL PERMIT (*Note:Some permits may rcquire approval by the E3uilding Official and/orPublic Works Department*) (ALL PERMITS- Mav be subiect to further review and mav not be issued when the anulication is received) GENERAL INFORMATION l. You may apply for utility permits by mail or in person at the City offices. 2. Mailed in applications are subject to the postage and handling fee shown below. Perrnit cards will be sent by return mail within 2 business days. 3. Permits are not valid until you receive a permit card. 4. Work 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 permit does not grant this approval. 7. All work must be done in accordance with State Code requirements. 8. All work must be inspected befare it is covered. Call (952)249-4600,24+hour notice required. TYPE OF PERMIT Check All That A 1 ,�Residential (May Require Approval) �Commercial (Approval Required) ❑ New Connection ❑Additional Connection ❑ Re-Connection ❑ Repairs Disconnect ❑ Water Availability Connection For Future Hook-Up to Water Job Site/Owner Information: f � /�� Site Address: ��7� S[�ci c�v �J��a� ��C�' Owner: � tev� �e� � Mailing Address: City: U��' � O Zip: Lii.J../'�� e, \ Home Phone:t ' S 2) j 5 � � �e S Alternate Phone: Contractor Information: Contractor: ��`r� �� ►'"i��'� ContactPerson: ��In � Address: �1 `1 d 5 ��° �I " State License #: � �' � I � 7 ` l�� City: S�� -� Zip:55�� Expiration Date: /2 3/ o�� Phone: ��95z> aya ''z`� � Alternate Phone: � � DETERMINING PERMIT FEES ❑SAC Charge(2010 Rate=$2,100.00) $ (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 Conne �on/Disconnect/ pair($50.00/Per Stub) $ �� Pipe size inches;materia] Schd 40 air tested; cast iron �Water Connectio �sconnect/ epair($50.00/Per Stub) $ ��• �� Pipe size in hes;material Schd 40 air tested; copper ❑Water Availability For Future Hook-Up to Water($50.00) $ Water Availabilitv Explanation: Contractor installed]ine to inside of house for future hook-up. This line will be inspected by the Public Works Department. Required Before Water Connection Permit is Issued: 1. Issue Water Meter&Horn Permit 2. Any Additional Connection Fees Paid(If Applicable) Issue Water Connection Permit: 1. Collect Permit Fee&Issue Water Connection Permit 1. SUBTOTAL of Permit Requested: $ ��. �v 2. STATE SURCHARGE $ .50 3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2� 4. TOTAL PERMIT 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 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 work in strict accordance with the ordinances of the City and the regulations of the State of Minnesota,and certifies that all statements made on this application are,true and correct. � � � -7 �o Applicant: Date: Reset Form