HomeMy WebLinkAbout2012-00122 - disconnect sewer/water � � " CITY OF ORONO PERMIT NO.: 20�2-00�22
2750 KELLEY PARKWAY
ORONO,MN 55356- DATE IssuEn: 02/16/2012
952 249-4600 FAX: 952 249-4616
ADDRESS : 3508 IVY PL
PIN : 20-117-23-42-0024
LEGAL DESC : TAYLORS SUBD OF SPRING PARK LO
: LOT 183 BLOCK 000
PERMIT TYPE : SEWER&WATER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DISCONNECTION
NOTE: WATER&SEWER DISCONNECTION PERMIT
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
J.S. STEWART COMPANIES INC. WATER CONNECT/DISCONNECT/REPAIR 50.00
16400 OLD ROCKFORD ROAD
PLYMOUTH,MN 55446 STATE SURCHARGE SEWER&WATER 5.00
(612)509-9011 TOTAL 105.00
Minnesota State License#: 1470
OWNER
WILSON, STEPHEN
3510 NY PL
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,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 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
revoke�at any time for du cau .
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Applicant e itee Sig ature Date Issu By Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
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City of Orono Date Receive Z Permit# � �a— �
�¢��� P.O.Box 66
� � 2750 Kelley Parkway ❑In-House SAC Determination Form Completed
9 �,y�;• Crystal Bay,MN 55323
��e ,�_��.��� (952)249-4600 Approved By(If Required):
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CITY OF ORONO—SEWER& WATER/GENERAL PERMIT
(*Note:Some permits may require approval by the Building Official and/or Public Works Department*)
(ALL PERMITS- Mav be subiect to further review and mav not be issued when the auolication is receivedl
GENERAL INFORMATION
1. You may apply for utility permits by mail or in person at the City offices.
2. Mailed in applications are subject to the postage and handling fee shown below. Perrr►it cards will
be sent by return mail within 2 business days.
3. Permits are not valid ,intil you receive a permit card.
4. VVork must not begin unless the permit card is avai[aole on the 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 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.
8. All work must be inspected before it is covered. Call(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
❑ Water Availability Connection For Future Hook-Up to Water
Job Site /Owner Information:
Site Address: 3�U� � ���/ �� ���� �
Owner: ` �b � � c-� �-c'_✓ __ Mailing Address: ��C� I v"�j (���.�C�,
City: (�Y C�n0 Zip: � `� ��1 �
Home Phone: �' I Z - (v 7 L � C:�`j���; Alternate Phone: ��I Z - _3(n � �-�, 7`1 �
Contractor Information:
Contractor: ,��S-��:c.�`C�u � (�U � ��_� Contact Person: ���t���S � '�t,c..`G-��
Address: � �CG��I `-Gt vti1G✓I�`��V'�N�State License#:
Ciry: �, 1(� J�v Zip:.`��3�I� Expiration Date:
Phone: 1 Lv.�-4Zy-��t U��� Alternate Phone: (v l Z-���� ��'�`t I
DETERMINING PERMIT FEES
❑SAC Charge(2012 Rate=$2,365.00) $
(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 Connectio /Disco� nn—e� epair($50.00/Per Stub) $ �J�
Pipe size inches;material Schd 40 air tested; cast iron
�.,;_.
�Water Connectio Dis��—conn t/Repair($50.00/Per Stub) $ ��
Pipe size i r�al Schd 40 air tested; copper
❑Water Availability For Futur�Hook-Up to Water($50.001 $
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:
l. Issue Water Meter&Horn 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. STATE SURCHARGE $ � 5.00,�'
3. POSTAGE&HANDLING(Only on Mail-In Applications) $ � 2.00�
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4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $ !D 1
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 sealed by Orono Water Department (952) 249-4600, upon
completion of ineter 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 e�ifies th al'�statements made on this application are,true and correct.
Applicant: Date: G—' �' 0 �
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