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Home My WebLink About2016-01509 - sewer/water disconnect CITY OF ORONO * z 0 1 6 - 0 1 5 0 9 * r . " 2750 KELLEY PARKWAY DATE ISSUED: 12/OU2016 ORONO, MN 55356- (952) 249-4600 FAX: (952) 249-4616 ADDRESS : 2800 SHADYWOOD RD P[N : 21-117-23-13-0023 LEGAL DESC : REG. LAND SURVEY NO. 1196 : LOT 000 BLOCK 000 PERMIT TYPE : SEWER&WATER PROPERTY TYPE : RESIDENTIAL CONSTRUCTIOI�T TYPE : DISCONNECTION APPLICANT SEWERCONNECT/DISCONNECT/REPAIR 50.00 WATERCONNECT/DISCONNECT/REPAIR 50.00 HAVEL EXCAVATING STATE SURCHARGE SEWER&WATER 1.00 10415 CAIN RD ROGERS, MN 55374- TOTAL 101.00 (612)363-4533 Payment(s) CHECK 4529 101.00 OWNER BERGH, HANS& SHARON 2800 SHADYWOOD RD EXCELSIOR, MN 55331- AGREEMENT AIYD 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 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 conformance with the State Building Code.This permit may be �� revoked at any time for due cause. i / �—'S� � j-��_��., I� � �� C� pplic t Pe itee ignature Date Issued By Sig ture Date .. `'� � .�L ,� „ FOR C T USE ONLY � � �0�/O,, Clty Of�['O�o Date Received: __��1��ermit# � P.O.Box 66 �'Y��i�� ` 2750 Kelley Parkway ❑In-House SAC Determination Form Completed ,"\'��,} ; Crystal Bay,MN 55323 \"'�^��ti�,` (952)249-4600/Fax(952)249-46i6 Approved By(If Required): fSN� CITY OF ORONO-SEWER& WATER/GENERAL PERMIT (*Note:Some}�mits may require approval by the Building Of�icial and/or Public Works Department�) (ALL PERMIT'S- May be subiect to further review and mav not be issacd w6en the aanlication is reeeivedl GENERAL INFORMATION 1. You may apply for utility permits by mail or in person at the City oflfices. 2. Mailed in applications are subject to the postage and handling fee shown below. Pernut cards will be sent by return mail within Z 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. S. Utility connection permits may be issued to licensed contractors only. 6. Contact the Public Works Department(952-249-4600)for utility stuh as-built locations. DO NOT F.XCAVATE IN ANY STREET AND DO NOT TAP ANY MAIN without express appmval of the Public Works Department. Issuance of a pemut dces 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. Call(952)249-4600,24+hour noNce required. TYPE OF PERNIIT 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: Site Address: �U�� J��\J n��O c-�_�(�z � �1(`c�� C.�ntr�;,;- ' Owner:C,Ycc 1� �l\�.U.S1bm��nr�� Mailing Address: �� `J� �vY'�h YtS�r-�-��. c�ry: �.1�� C rr,v L z�p: �553 I � Home Phon��53-�3a� Alternate Phone: 11� �'�5y�" Q`�Xl�c_t�� Contractor Information: ��Z..L�1 �-Jt,Y�.z..� �12vr/1�-nC� Contractor: �2�-ca�jc�„z v�.}-�n,�,� Contact Person: �� S �2�e1 �r'. Address:1�-�tiCz,n� 1�0 State License#: -L1�Qa�1,p�1 City: Zip�3�1�- Expiration Date: �a • 3l• �l al Phone: ��i��S-��`� � Alternate Phone: ( I D la T�JId�-4�3� l 1(��1.ay I� ��j�prj�ll� 1-'►�e�r.S�e�- 1"a ,3� 13 �►P��s ��.-��a,4o s" , . .. ,,,.� .. 'Y� r x�i��b°�vK��Y.�K'� }5� .,.,,� .. . , � ; -� s.�.. � � � ❑SAC Chatge(2016 Rate=$2,485.00) $ (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 Issaed) ❑Sewer Connection isconnect Repair($50.00/Per Stub) $ �V Pipe size inches;material Schd 40 air tested; cast iron ❑Wster Connection 'sconnec Repair(550.00/Per Stab) $ �� Pipe size inches;material Schd 40 sir tested; copper ❑Water Availability For Fbtare Hook-Up to Water(S511.00) $ Water Availabilitv Ezalanation: Contractor installed line 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&Hom 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: $ � �� 2. STAT'E SURCHARGE $ 1.00 3. POSTAGE&f�NDLING(Only on Mail-In Applications) $ 2.00 4. TOTAL PERMiT FEE(Add Lines 1-3 Above) $ L V � . ADDITIONAL INFORMATION—WATER METERS • WATER METERS must be picked up and paid for at Orono City Hall,these are on a se arate permit. ■ WATER METERS must be set and sesled by Orono Water Department(952)249-4600, upon completion of ineter installation. The undersigned hereb applies to the City of Orono for issuance of a Utility Permit,agrees to do all work in stric o e with the ordinances of the ' and the regulations of the State of Minnesota,and rtifies t all sta.tements made ' ap ication are,true and correct. Applicant: Dat+�.` '�