HomeMy WebLinkAbout2014-00542 - sewer re-connect ..,; .:
CITY OF ORONO * 2 0 1 4 - 0 0 5 4 2 *
, 2750 KELLEY PARKWAY DATE ISSUED: 06/02/2014
' ORONO, MN 55356-
(952) 249-4600 FAX: (952) 249-4616
ADDRESS : 1645 BOHNS POIN'T' RD
PIN : 17-117-23-11-0007
LEGAL DESC : REG. LAND SURVEY NO. 0565
: LOT 000 BLOCK 000
PERMIT TYPE : SEWER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : RE-CONNECT
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
STATE SURCHARGE SEWER&WATER 5.00
UNLIM[TED, INC.
19960 ST FRANCIS BLVD TOTAL 55.00
ANOKA, MN 55303- Payment(s)
(763)753-9867 CHECK 1008 55.00
OWNER
CHURCH,JOHN& KLERISSA
1645 BOHNS PT RD
WAYZATA, MN 55391-
AGREEMENT AND SWORN STATEMENT
The work for which this perniit is issued shall be perlormed 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
pennits. All provisions of laws and ordinances governing this type of work
shall be compied with whether or not specitied herein.This permit will
expire and become null and void if construction authorized is not
commenced within 180 days o�the date of issuance,or if construction is
suspended for a period of 1 days at any[ime after work has commenced.
I he applicant is respons e for assuring all required inspections are
requested in conform�e with the State Building Code.This permit may be
revoked at any time,.�fr due cause.
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Applica(t��P m�tee ignature Date Issued By gnature Date
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FOR CITY USE ONLY
,y,'.,`�-�'��� L Clty of Orono Date Received: Permit#
;;� � P.O.Box 66
� 2750 Kelley Parkway ❑In-House SAC Determination Form Completed
1�.\� i � Crystal Bay,MN 55323
��� •'�`'� (952)249-4600/Fax(952)249-4616 Approved By(lf Required):
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CITY OF ORONO—SEWER& WATER/ GENERAL PERMIT
(*Note:Some permiu may require approval by the Buildin�Official and/or Public Works Department*)
(ALL PERMITS- Mav be subiect to further review and mav not be issued when the appGcation is received)
GENERAL 1NFORMATION
1. You may apply for utility permits by mai]or in person at the City 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 unril you receive a permit card.
4. Work must not begin unless the permit card is available on tbe 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 a.s-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 before it is covered. Cail (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
❑ R'ater Availability Connection For Future Hook-Up to Water
Job Site/Owner Information:
SiteAddress: ���� ��h��s �����1� ��
Owner: l��t rC�1 Mailing Address:
City: (�TOnU Zip:
Home Phone: Alternate Phone:
Contractor Information:
(�in��/'�i �-�c! 1��• ContactPerson: !`�ul/M �/lrT�'��S
Contractor: � '
Address: �y�/�0� .St-�t'c�nL,`5 ���c� State License#: �I ���`) ��.�y
City: l� Zip:553U3 Expiration Date: ��� J�I��l5
Phone:
��3"��f��'� ��'f�0 Alternate Phone:
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DETERMINING PERMIT FEES
❑ SAC Charge(2014 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 issued)
Sewer Connection/Disconnect/Repair($50.00/Per Stub) $ 1 Url-GC�
Pipe size�inches;material�'l�L Schd 40 air tested; cast iron
❑Water Connection/Disconnect/Repair($50.00/Per Stub) $
Pipe size inches;material Schd 40 air tested; copper
❑Water Availability For Future Hook-Up to Water($50.00) $
Water Availabilitv Explanation:
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&Horn Permit
2. Any Additional Connection Fees Paid(If Applicable)
Issue Water Connection Permit:
l. Collect Permit Fee&Issue Water Connection Permit
1. SUBTOTAL of Permit Requested: $ /(��-�lJ
2. STATE SURCHARGE $ 5.00
3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $ �Q �U(�
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 undersitmed hereby applies to the City of Orono for issuance of a Utility Permit, agrees to do
all work in strict accordanc with the ordinances of the City and the regulations of the State of
Minnesota, and certifies at all statements made on this application are,true and correct.
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Applicant: �( � - Date: ��'v�'� �6 t/