HomeMy WebLinkAbout2009-00880 - sewer disconnect . � CITY OF ORONO PERMIT NO.: 2009-00880
2750 KELLEY PARKWAY
ORONO, MN 55356- DATE ISSUEn: 12/07/2009
952 249-4600 FAX: 952 249-4616
ADDRESS : 1785 CONCORDIA ST
PIN : 17-117-23-22-0016
LEGAL DESC : COFFEES ADDN TO SHADY WOOD LAK
: LOT 000 BLOCK 000
PERMIT TYPE : SEWER
PROPERTY TYPE : RES[DENTIAL
CONSTRUCTION TYPE : DISCONNECTION
NOTE: SEWER DISCONNECTION
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
UP NORTH MECHANICAL STATE SURCHARGE SEWER&WATER 0.50
43900 ELMCREST AVE
P.O. BOX 35 TOTAL 50.50
HARRIS, MN 55032 PAID W[TH CC# 3902
(651)277-OS 15
OW1vER
DULIN, KEVIN & BARBARA
1785 CONCORDIA ST
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,appiicablc City approvals,and the
State Building Code. This permit is for only the work described and does
no[grant permission for additional or related work which requires separate
permits. All provisions of laws and ordinances governing this type of work
shall be compie whether or not specified herein."�his permit will
expire and ome n II and void if construction authorized is not
commen �it in 80 days of the date of issuance,or if construction is
suspen for p iod of 180 days at any time after work has commenced.
The plica is esponsible for assuring all required inspections are
re t � c nfon with the Statc Building Code.This permit may be
re o for due cause.
i i �� /� a7 0�
A cant Permitee Signature Date Issu Qy Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
12/07/2009 10:15 FAX 1�001/002
. FOR�7`�—SE ONLY
ir '"�'`" Clty of Orono Date Received:/ O�ermit t1�60 -- �
.�� �� P.O.Box 66
''�•" ` 2�50 Kelle
�, �{G;�,;,, �,; y Parkway ❑In-House SAC Determination Form Com leted
I '41� `{y�'�y`4, +�!', Crystal Bay,MN 55323 p
`�\+'°`�,�� i� (9i2)249-4600 Approved By(If Required):
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CITY OF ORONO-SEWER& WATER/ GENERAL PERMIT
, "Note:Some permi[s may require approval by the Building Official and/or Public Works Department*)
ERVIITS- a e sub'ect f u er re few a d no e iss when t e a icatio 's iv d)
GENE L INFORMATION
]. Y u may apply for utility permits by mail or in person at the City offices.
2, ']ed in app]ications are subject to the postage and handling fee shown below. Permit cards will
I be ent by return mail within 2 business days,
3. Pe mits are not valid until you receive a permit card.
4. VV rk must not begin unless the permit card is available on the job site.
5. U ity connection permits may be issued to licensed contractors only.
6. Coptact the Pubiic Works Deparhnent(952-249-4600)for utility stub as-built iocations.
� DC�NOT EXCAVATE IN ANY STREET AND DO NOT TAP ANY MA,IN without express
approval of the Public Works Department. Issuance of a permit does not grant this approval.
i 7, All work must be done in accordance with State Code requirements.
8. A!1 work must be inspected before it is covered, Call(952)249-4600,24+hour notice required.
� TYPE OF PERMIT
i Check All That A 1
� �Residential(May Require Approva[) ❑ Commercial(Approval Required)
j ❑ New Connection ❑Additional Connection ❑Re-Connection ❑ Repairs �Disconnect
❑ Water Availability Connection For Future Hook-Up to Water
� Job Site/Owner Information:
Site Address: 17`�� Coac�rl;y
Owner: }C��}a ��,.I��► Mailing Address: S-n<-
CitY� ��c"'0 Zip:
Home Phone: q52-�I'7—55'�o. Alternate Phone: c�I Z•Z6�-�7 0
; Contractor Information:
I Contractor: yr ��� Contact Person: �,i,�
Address: ��-�y00 ��� ��{ State License#:
�I City: �,U''�''l5 Zip: Expiration Date:
' Ph ne: � iz - �77-U-5�� AlternatePhone;
12/07 2009 10:15 FAX C�002/002
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❑ SAC Charge(2009 Rate=�2,000.00) g
,(SAC Charge must accompany all sewer permit applications unless prepaid)
(Orono City Staff can detarmine if applicable)
(If not prepaid,a sewer connection permit will not be issued)
I wer Connection/Disconnect/Repair($50.00/Per Stub) $ � �
Pipe size inches;material Schd 40 air tested; cast iron
❑'Water Connection/Disconnect/Repair(550.00/Per Stub) $
Pipe size inches;material Schd 40 air tested; copper
I
❑ ater Availability For Future Hook-Up to Water(550.00) $
Water Availabjlitv Exulanation:
Contractor installed line to inside of house for future hook-up.
This line will be inspected by the Public Works Department.
Reauired Betore Water Connection Permit is Issued:
� ]. Issue Water Meter&Horn Permit
2. Any Additional Connection Fees Paid(If Applicable)
L�sue Water Connection Permit:
1. Collect Permit Fee&Issue Water Connection Permit
1. UBTOTAL of Permit Reguested: $ � . �
2. ATE SURCHARGE $ ,50
3. OSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00
4. OTAL PERMTT FEE(Add Lines 1-3 Above) � ,� . ,�
ADDITIONAL INFORMATION—WATER METERS
■ WATE METERS must be picked up and paid for at Orono Ciry Hall,these are on a separatepermit.
■ WATE METERS must be set and sealed by Orono Water Department (952) 249-4600, upon
complet n of ineter installation.
The undersi ned here pplie o the City of Orono for issuance of a Utility Permit,agrees to do
alI work in trict o ance ith the ordinances of the City and the regulations of the State of
Minnesota, d i e a statements made on this application are, true and correct.
Applicant: Date: � 7 o y