HomeMy WebLinkAbout2017-00681 - sewer disconnect 1111111111111111111111111111 IN lilt M
CITY OF ORONO * 2 0 1 7 - 0 0 6 8 1
r 2750 KELLEY PARKWAY DATE ISSUED: 06121/2017
ORONO, MN 55356-
(952)249-4600 FAX: (952)249-4616
ADDRESS 1020 TONKAWA RD
PIN 08-117-23-13-0014
LEGAL DESC REG. LAND SURVEY NO.0617
LOT 000 BLOCK 000
PERMIT TYPE SEWER
PROPERTY TYPE RESIDENTIAL
CONSTRUCTION TYPE DISCONNECTION
NOTE: SEWER DISCONNECT
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
STATE SURCHARGE SEWER&WATER 1.00
BOLLIG&SONS,INC. TOTAL 51.00
11401 COUNTY ROAD 3
HOPKINS,MN 55343- Payment(s)
(952)938-4133 CREDIT CARD 9081 51.00
OWNER
BURKE,FORREST
380 LEAF ST
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 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 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.
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Applicant Permitee Signature Date Issued E0 Signature Date
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1' s6QNLN
0NO City of Orono Dau Rcc Permit ft
\ 'so hcllcy Parkes,y ❑In-Hou►c SAC Dctcrtnimtion form Con,pleud
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11 i n1stal Bay,NIN 55323
i?S21 49-4600 f,s{os2)149-.itiln Approved fly(if Requtredy _.
CITY OF ORONO-SEWER& WATER I GENERAL PERMIT
t•Notc Sonicpenwts may rcquwrc apprw'al b%,hc build f Official and,+u Public Works Dcpartmcnt')
(AI.L PER. ITS• l�1ay he wubfrct to further rr,leN and mar'not be Issued wbrn rhe auglkallat is rrcetvedt
GENERAL INFORMATION
1 You may apply for utility pennits by mail of in person at the Citv 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. Work must not begin unless the permit card is available on the job site.
5. Utility connection pemnits 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.
S. All work must be inspected before it is covered. Call(952)2494600,24+hour notice required,
TYPE OF PERMIT
Check All That Apply)
9 '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 Informations
Site Address:
Owner: `� �`Q-4-' ' " Mailing Address:
City: Zip:
Home Phone: Alternate Phone:
Conftctr titin �' "
Contractor: 31- Ii:y S o-. S Contact Person: M
Address: It,(o c t e State License#: L Ob-
City:
lb-City: � -� 'S Zip:5"4 Expiration Date: t2-3 (• t '
Phone: �1?'2- A�tc Phone: (t2 `(3`f
F SAC Charge(2016 Rate=$2,485.00) $
(SAC"Charge must acamrpauy all sr"cr pont applications unless prepind)
((Arno Cite Start can detctmunc it applicable)
�lf not prepaid,a sc%cr connection permit will not be issued)
Sewer Connection/Disconnect i Repair($50.00/Per Stull) S
Pipe size inches;material Schd,10 air tested;. __cast iron
0 Water Connection/Disconnect/Repair($50.00/Per Stub) $�
Ptpc sire mchcs;material Schd 40 air tested: copper
0 Water Availability For Future Hook-Up to Water(550.00) 5
Water Avuilabili(v Explanation: j
I
Contractor installed line to inside of house for future hook-tip
This line will be inspected by the Public Works Department. t
Required Before 'Vater Connection Permit is Issued:
1. Issue Water Meter&Horn Perrot
.Any Additional Connection Fees Paid(If Applicable)
� I
Issue Water Connection Pcrmie
1. Collect Permit Fee&Issue Water Connection Permit
! I
1. SUBTOTAL of Permit Requested: $ �!/iyV
2. STATE SURCHARGE $ 1.00
3. POSTAGE&HANDLING(Only on Mail-in Applications) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $_v _aV
ADDITIdNAh:WQRMATION-WATER METERS
• WATER METERS must be picked up and paid for at Orono City Hall,these arc on a separate permit.
• WATER METERS must be set and sealed by Orono Water Department (952)2494600, upon
completion of meter 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 cer7= /Date:
application are,true and correct.
Applicant: _
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