HomeMy WebLinkAbout2011-00376 - water meter CITY OF ORONO PERMIT NO.: 2011-00376
4 -- �� 2750 KELLEY PARKWAY
? < <� � ORONO, MN 55356- DATE ISSUEn: 05/23/2011
;
952 249-4600 FAX: 952 249-4616
ADDRESS : 2256 SHADYWOOD RD
PIN : 17-117-23-43-0125
LEGAL DESC : WILEYS PARK LAKE MTKA
: LOT 006 BLOCK 001
PERMIT TYPE : WATER METER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : WATER METER
NOTE: INSEPCTIONS ARE DONE BY PUBLIC WORKS DEPARTMENT.
TO SET-UP AN INSPECTION,PLEASE CALL:(952)249-4613
WATER METER RESIDENTIAL 1
APPLICANT WATER METER RESIDENTIAL 303.70
MITCH JOHNSEN TOTAL 303.70
�2184 SHADYWOOD RD
WAYZATA,MN 55391- PAID WITH CC# 4350
(763)SOCr0629
OWNER
BURKE,FORREST&RENEE
2256 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 sepazate
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 after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked at any time for due cause.
/ / / /
Applicant Permitee Signature Date Issued By Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
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FOR CITY USE ONLY
�'"'�� Cit of Orono
�/¢O�\� P.O Box 66 Date Received: Permit#
�/ _.�,.,._,, �`I 2750 Kelley Parkway
� 11��r}`- !� Crystal Bay,MN 55323 Approved By:(If Required):
' ;� ��p a� (952)249-4600
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CITY OF ORONO-WATER METER FORM
(*Note:Some permits may require approval by the Building Official and/or Public Works Department*)
GENERAL INFORMATION
1. WATER METERS must be picked up and paid for at City Hall.
2. If possible,fax in this application ahead of time;we will then call you and let you know we have
the water meter in stock. Fax Number: (952)249-4616. Also,you can call ahead of time to make
sure we received the fax,or to warn us that the fax is coming.
3. WATER METERS must be set and sealed by Orono Water Department (952) 249-4600,
upon completion of ineter installation.
TYPE OF PERMIT
Check All That A 1
❑ Residential (May Require Approval) ❑Commercial (Approval Required)
� New Meter � Additional Meter—For: �erfacement Meter
Job Site/Owner Infoimation:
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Site Address: ��-2 � �% ����.«�( ��' d � � �`
Owner: �%���5`� � V �- Mailing Address: �����'�'�'
City: Zip:
Home Phone: � � 2 � � � �v� 2- Alternate Phone: � � 3 �-��� � � Z �
Contractor Information:
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Contractor: M��� �•,� U��S Contact Person: � �'�`��
Address: �� �d� S�uof y�'�'�� �`�State License#:
City: v v`�"� Zip:s S 3� ,Expiration Date:
Phone: G 3 �G 6 D(n Z
�� � � Alternate Phone:
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WATER METER PERMIT FEES
WILL BE CAULULATED BY CITY STAFF
❑ 5/8"METER- 0 3/4"METER- � 1"METER-
� 5/8"HORN - ❑ 3/4"HORN - � 1"HORN -
� "WATER METER (THESE WILL HAVE TO BE SPECIAL ORDERED&PRICES DETERMINED)
1. METER FEE: $
2. HORN FEE $
3. TOTAL PERMIT FEE(Add Lines 1-2 Above) $
CITY-USE ONLY
* For Current Pricing Refer to Current Year- Water Meter Pricing Chart *
BRAND: 3` �� 7�
SIZE: ❑ 5/8" [►�3/4" ❑ 1" ❑Other "
SERIAL#:
ERT HIGH#: (if applicable)
ADDITIONAL INFORMATION—WATER METERS
The undersigned hereby applies to the City of Orono for issuance of a water meter perinit, agrees
to do all work in strict accordance with the ordinances of the City and the regulations of the State
of Minnesota, and certifies hat all statements made on this application are,true and correct.
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Applicant: �% L'-' Date: / ! �
Reset Form
Original: I-Address File
Make Copies For�: l- Utiliry Billing Departme�zt 1-Cash Drawer
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❑ 5/8"METER- ❑ 3/4"METER- � 1"METER-
❑ 5/8"HORN - ❑ 3/4"HORN - ❑ 1"HORN -
❑ "WATER METER (THESE WILL HAVE TO BE SPECIAL ORDERED&PRICES DETERMINED)
1. METER FEE: $
2. HORN FEE $
3. TOTAL PERMIT FEE(Add Lines 1-2 Above) $
CITY-USE ONLY
* For Current Pricing Refer to Current Year-Water Meter Pricing Chart *
BRAND:
SIZE: ❑5/8" ❑3/4" ❑ 1" ❑Other "
SERIAL#:
ERT HIGH#: (if applicable)
ADDITIONAL INFORMATION—WATER TERS
The undersigned hereby applies to the City of Orono for issuance of a ter meter permit, agrees
to do all work in strict accordance with the ordinances of the City and th regulations of the State
of Minnesota,and certifies that all statements made on this application ar ,true and correct.
Applicant: Date: �c.Q- lo-C_--Qo.D
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Original: 1-Address File
Make Copies For: 1- Utility Billing Deparhnent 1-Cash Drawer
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FOR CITY USE ONLY
O,�p�O City of Orono
P.O.Box 66 Date Received: Permit#
�,,,,,� 2750 Kelley Parkway
��yr1�,''� Crystal Bay,MN 55323 Appmved By:(If Required):
}o�� (952)249-4600
CITY OF ORONO—WATER METER FORM
(*Note:Some permits may require approval by the Building Official and/or Public Works Department'")
GENERAL INFORMATION
1. WATER METERS must be picked up and paid for at City Hall.
2. If nossible,fax in this application ahead of time;we will then call you and let you know we have
the water meter in stock. Fax Number: (952)249-4616. Also,you can call ahead of time to make
sure we received the fax,or to wam us that the fax is coming.
3. WATER METERS must be set and sealed by Orono Water Department (952) 249-4600,
upon completion of ineter installation.
TYPE OF PERMIT
Check All That A 1
❑Residential(May Require Approval) ❑Commercial(Approval Required)
❑New Meter ❑Additional Meter—For: �Replacement Meter
Job Site/Owner Information:
Site Address:
Owner: Mailing Address:
City: Zip:
Home Phone: { Alternate Phone:
Contractor Information:
Contractor: Contact Person:
Address: State License#:
�
City: Zip: Expiration Date:
Phone: Alternate Phone: