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CITY OF ORONO PERMIT NO.: 2010-00934
2750 KELLEY PARKWAY
ORONO, MN 55356- DATE ISSUED: 10/04/2010
952 249-4600 FAX: 952 249-4616
ADDRESS : 4360 SIXTH AVE N
PIN : 31-118-23-12-0011
LEGAL DESC : SHARON HILLS
: LOT 006 BLOCK 001
PERMIT TYPE : PLUMBING(<$500)
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : WATER SOFTNER
NOTE: WATER SOFTENER
APPLICANT PLUMBING FIXTURE FEE(<$500) 15.00
CULLIGAN SOFT WATER SERVICE CO. STATE SURCHARGE PLBG(<$500) 5.00
6030 CULLIGAN WAY
MINNETONKA,MN 55345 MAIL-IN FEE 2.00
(952)912-7379 TOTAL 22.00
PAID WITH CC# 0597
OWNER
HIBBS, WILLIAM
4360 SIXTH AVE N
LONG LAKE,MN 55356-
AGREEMENT AND SWORN STATEMENT
The work for which this permit is issued shall be performed according to
the approved plans and specifications,applicable City approvals,and the
State Building Code. This permit is for only the work described and does
not grant permission for additional or related work which requires sepazate
permits. All provisions of laws and ordinances goveming this rype of work
shall be compied with whether or not specified herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days of the date of issuance,or if construction is
suspended for a period of 180 days at any time after work has commenced.
The applicant is responsible for assuring all required inspections are
requested in conformance with the State Building Code.This permit may be
revoked any time for due cause.
U' l �U �(J l l �C./
Applicant Permitee Sign Date Issued Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
10/O1i�2010 15:10 FAX 9529335049 CULLIGAN �NTRA f�002
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FOR CTIY t1S�ONLY
Ci of Orono /(�
O���� P:.Box 66 Dete Received: �Permit N ��r ��
2750 Kelloy Patkway +�
C r Ctystel Bay,MN 55323 Approved By: Amount$: otia•
��b� (952)1A9-4600
CITY OF ORONO-PLIJNIBING PERMIT
(All Commercial permits muat tie approved by the Building OtFcial or lnepactor)
GENERAL INFORMATION
l. You may apply for plumbing permits by mail or in person at the City offices. Applications will be
reviewed and a permit will be issued within two working days.
2. Permit cards wiU be sent by retum mail after a review is completed. PE1tMITS ARE NOT
VALID UNTIL YOU RECENE A PERMIT. WORK MilS�'NOT BEGIN UNTII.TAE
PERMIT CARD IS POSTED ON THE JOB SITE.
3. Plumbing permits may be issued ONLY to licensed plumbing co�rtractors and to properry ovmers
residing in the dwelling.
4. When any new conswction or romodeling is involved,a seperak building permit must be
obtained.
S. All work must be done in accotdance with 6tate Code requirements.
6. All work must be inspected and air testod before it is covered. Call(952)249-4600.
(Z4-48 6our notice reqniro�
TYPE OF PERMIT
Check All That A 1
�j Residential ❑Commcrcial(Approval Required)
/ `
❑New ❑Additional ❑Repairs �Replace
❑ In Accessory Structure7
*You will need nrior anuroval and may need G'l�.(Per Orono Ciiy Code,Chapter 78,Article IV)
7ob Site/Owner Information:
Site Address: ��� `� � �P �
-r---
Owner: � � � ( �`�� b� Mailing,Address:
City: Zip: SS ���
Home Phone: Alternate Phone: ��2� g�'�����
Contractor Information:
CULLIGAN 1�VATER CONDITIONIN�.
Contractor: Contact Person: � 60�CULLIGAN WAY
55346
(962) 933-7200
Address; State Bond#: '
City: Zip: Expiration Date:
Phone: Alternate Phdne:
❑ Insurance—Current:
1
10/0 L`2010 15:10 FAX 9529335049 CULLIGAN MNTKA �003
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F[XTURE BSMT 1 2 OTHER FIXTURE BSMT ] 2 OTHER
TYPE FL FL TYPE FL FL
Water Closet Floor Drains '
Lavaiory Sewer Ejactor
Bathtub Laundry Tray
Shower Washer
Kitchen Sink Water Heater
Disposal Water Softaner
Dishwasher Wet Bar
Sillcocks Miscellaneous
4,, �
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Yes,this section applies
The replacement of a Residential fixture or apeliange that meets all three of the following requirements:
1, oes require modification to electrical or gas servica.
2. Has a total cost of$500.00 or less;excludins the cost of the fixture or appliance:and -�"��
3. Is improved,installed or replaced by the homeowner or licensed contractor.
Skip next scetion,if this applies; Cost of Permit $ 15.00
State Surcharge $ 5•00
Mail-In Fee(If Applicable) $ 2.00
Tota!Permit Fee $�_d�
(Permit Fees Continued Oa Next�age)
2
10/O1/�2010 15:11 FAX 9529335049 CULLIGAN MNTRA f�004
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If above does not apply;follow guidelines belaw:
1. CONTRAGT PRYCE * is 1.25%of contract price with a(Minimum Fce of SS0.00)
x.0125$
(contract price) (minimum$50.00)
2. STATE SURCHARGE '"*Add the State Bldg Code Div.Surcharge(Mioimum Fee otS5.00)
x.0005 $
� (contracl priu) (minimum S 5.00)
3. POSTAGE&HANDLING(Only on Mail-Tn Applications) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) S
• � CONTRAC'f PRJCE or JOB COST means the actual or estimated dollar amount charged for the
permitted work including materiels,Iabor,profit,and othu fixed costa. It is the amount W be charged
to the customer for the work done. If any material,equipment,'labor o�installations are fumished by
the owner,tenant or any other party,the reasonable market value of such items must be added to the
estimated cost or eontract price for permit fee purposes. In the event that there is a dispute on the
amount of the job cost,the City may request the submission pf a signed c,opy of the actual contract.
■ **The STATE SURCHARGB is.0005 of the contract price under$],000,000 or$5.00—whichever is
groater. For valuations over SI,000,000 call the Building Depertment at(9S2)249-4600 for the price.
T6e undersigned hereby applies to the City for issuance of a Plumbing Permit, agrees to do all
work in sfict accordance with the ordinances of the City and the regulations of the State of
Minnesota, and certifies that all statements made on this application aze complete, true and
correct.
ApplicanYs Signature: ate: J� � �
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