HomeMy WebLinkAbout2005-P09204 - sewer/water connection PERMIT
CITY OF ORONO Permit Number:
2750 Kelley Parkway- PO Box 66 Po9204
Crystal Bay, Minnesota 55323 Permit Type: Sewer d Water Permit
(952)249-4600 Date Issued: 9/21/20 5
SITE ADDRESS: 2670 Kelley Pkwy(57 Unit Building) unit#
Long Lake,MN 55356
P��� 33-118-23-12-0012
DESCRIPTION:
Proposed Use: Residential
Permit Class: General
Pernut Type: Sewer and Water Pernut Permit Sub-type(s): Sewer&W ter Connecrions
DETAILS:
Approved per resolution#:
Separate pernuts required:
NOTICES/REMARKS:
FEE SUMMARY: Permit Fee: $ 70.00 Valuation: $ 0.00
State Surcharge Fee: $ 0.50
TOTAL FEE: $ 70.50
APPLICANT: Groth Water&Sewer OWNER: 3Z Holding
775 Tower Drive 10300 l Oth Avenue N
Hamel,MN 55340 Plymouth,MN 55441
TE�IE UNDERSIGNED HEREBY REQUESTS PERMISSION TO MAKE THE REAL IMPROVEMENTS SPECIFIED
AND AGREES TO DO ALL WORK IN STRICT COMPLIANCE WITH ALL CITY OF ORONO ORDINANCES AND S ATE OF
MINNESOTA BUILDING CODE REQUIREMENTS.
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PLIC PERMITEE SIGNATURE ISSUED BY SIGNATURE
Copies: 1-File(Signatures Required), 1-Applicant, 1-Monthly Reports, I-Assessing,(If Septic, 1-Septic) Page 1
FOIt C1TY USE ON[�Y.
,��� City of Orono Date Received: `l'2i-U� Permit# ��ZU
P.O.Box 66
��„.,;,,, O 27�0 Kelley Park�vay ❑Tn-House SAC Determination Form Completed
� ��jS��;z;' y Crystal Bay,MN 55323
�l'T��,��.�o (952)249-4600 Approved By(If Required)�
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CITY OF ORONO—SEWER& WATER/GENERAL PERMIT
(*Note:Some pennits 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 ann��cation is received)
GENERAL INFORMATION
1. You may apply for utility pernuts by mail or in person at the City offices.
2. Mailed ui applications are subject to the postage and handling fee shown below. Pernut 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 peinut card is available 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 Apply)
❑ Residential(May Require Approval) �] Commercial(Approval Required)
❑ New Connection ❑ Additional Connection ❑ Re-Connection ❑ Repairs ❑ Disconnect
Job Site/ Owner Information:
�
Site Address: �
Owner: �� ,�� �'/J Mailing Address:
City: Zip:
Home Phone: Alternate Phone:
Contractor Information: i
Contractor:�/�� W Contact Person: '���
Address: 7 � (� Gt��� �� State License #: �� ��
(�,
Cit C��' ✓ Zi �� ��Ex iration Date: `
Y� P� P 1 � � � � �
Phone: Alternate Phone: � � l C� / � (,� � � �
DETERMINING PERMIT FEES
❑ SAC Charge(2005 Rate=$1,450.00) $
(SAC Charge must accompany all sewer pernut applications unless prepaid)
(Orono City Staff can deternune if applicable)
(If not prepaid,a sewer connection permit will not be issued)
�'Sewer Connection/Disconnect/Repair($35.00/Per Stub) $
Pipe size�inches; material n,�_L _Schd 40 air tested; cast iron
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�Water Connection/Disconnect/Repair($35.00/Per Stub) $
Pipe size�inches;materialc-,�_;�Schd 40 air tested; copper
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1. SUBTOTAL of Pernut Requested: $
2. STATE SURCHARGE $ .50
3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 1.50
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $
ADDITIONAL 1NFORMATION—WATER METERS
■ WATER METERS must be picked up and paid for at Orono City Hall, these are on a s�arate pernut.
■ 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 far 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 certifies that all statements made on this application are, true and correct.
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A�plicant: Date: � �� �S