HomeMy WebLinkAbout2014-00919 - sewer/water disconnect CITY OF ORONO * z 0 1 4 — P1 PJ 9 1 9 *
� 2750 KELLEY PARKWAY DATE ISSUEU: 08/20/2014
�,/� ORONO, MN 55356-
��j � (952) 249-4600 FAX: (952) 249-4616
ADDRESS . 50 KELLEY PKWY
PIN : 33-118-23-12-0007
LEGAL DESC : CITY OF ORONO ADDN
: LOT 001 BLOCK 001
PERMIT TYPE : SEWER& WATER
PROPERTY TYPE : COMMERCIAL- BUSINESS
CONSTRUCTION TYPE : DISCONNECTION
NOTF.: SEWER&WA�I�ER DISCONNI:C�I'
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APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 0.00
WATER CONNECT/DISCONNECT/REPAIR 0.00
MINNESOTA UTILITIES& EXCAVA'TING STATE SURCHARGE SEWER& WATER 5.00
13932 LAKE DRIVE
FOREST LAKE, MN 55025- TOTAL 5.00
(651)464-5532 Payment(s)
Minnesota State License#: SW-4188 CHECK 5004 5.00
OWNER
City of Orono
ORONO, CITY OF
2750 KELLEY PARKWAY
P.O. BOX 66
CRYSTAL BAY, MN 55323-
AGREF,MENT AND SWORN STATEMENT
I�he work for which this permit is is,ued shall be performed according to
the approved plans and specitications,applicablc City approvals,and the
State[�uilding Code. "I�his permit is for only the work describcd and does
not grant permission for additional or related work which requires separate
permits. All provisions of la�vs and ordinances governing this type of work
shall be compied with whether or not specified herein.'i�his permit will
expire and become null and void i(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 arc
requested in conformance with the State Building Code.This permit may be
revoked at any time for due cause.
'"� X ` T . i� � i�Di
pplicant Permitee ignature D' c I ed By Signature Date
FO�SE ONLY
��/V� City ot Orono Date Received Pennit# Q -
Y.O.Sox 66
� 2750]:ellcy Parkw:iy ❑ln-House SAC Dztermination Form Completed
� � Cry�tal Ba�,MN 5>3?3
.,�i.�`��`
(952)249-4600/Fax(952)2�9-4616 AFfpro�ed By(lf Keyuired):
CITY OF ORONO-SEWER & WATER/GEIER�L PERMIT
(*5ote:Some permits may require xpproval bV the Ruilding Of(icial and/or Public Works Depwiment*)
(ALL PERD9lTS- D1av be subiect to further review and mav not be issued wl�en the application is receivedl
GENERAL 1NFORMATION I
1. You may apply for utility permits by mail or in person at the City offices.
�. Mailed in applications are subject to the postlge and h�ndling fee sho�vn belo�v. Pennit cards��-ill
be sent by return mail�i�ithiu 2 business days.
3. Permits are not valid until you receive a permit card.
4. Work nmst not begin uiiless lhc permil card is available on the job site.
5. Utility counection pernlits may be issued to liceused contractors only.
6. Contact the Public Works Depariment(952-249-4600)for utility stub as-built locations.
DO I�OT F,XCA�'A7'E IN A'VY STREI�;'1'ANll DO N07'7'AY ANl'n1AIN��ithout express
approval of the Public Works Department. Issuance of a pennit does not grant this approval.
7. All work must b�done in accordance tvith State Code requirements.
R. All work must be inspectecl before it is covered. Call(95�)?49-4600,24+hour notice required.
TYPE OF PERMIT
(Check All That A 1 )
❑Residential(\�[ay Require Approval) [✓YCominercial(Approval Requircd)
❑Ne�-Connection ❑Addilional Connection [�Re-Connection ❑ Repairs ❑ Discorulect
❑ Water A�ailability Connection }'or I'uture l-look-Up to Water
Job Site/Owuer Information:
Site Address: Z,'�3D K�L���t �A�c��k�
()wner: C�r�t oF �eoao MailingAddress: Z73o CFceEv t�'a�.t��Y
City: ��F,�sTq� �Ay Zip: �53z3
Home Plione: 4�1-L�(9-�/60o Alternate Phone:
Contractor lnformation:
Contractor: M�a�/ESorA Uri�iri£s �*EX��r�ContactPerson: �ec � � 1aK1
Address: �3q3z ��+� De�v� State License#: / �, G1ta�
City: �o¢fsf Lq�E Zip:55oZ Expiration Date: Ot�D��/y
Pllone: 651-�/6y '�5 3 Z Alternate Pl�one: (�Z-ZZ 3- 308y
, . �
DETERMINING PERMIT FEES
❑ SAC Charge(2014 Rate=$2,485.00) � �—
(SAC Charge n�ust accompany all sewei•pennit applications unless prepaid)
(Orono Cit}� Staff can determine if applicable)
(If not prepaid,a sewer connection permit�vill not be issued)
❑ Se«er Connec ion J llisconnect/Repair($50.00/Per Stub) $
Pipe size�inches;material SA�S�Schd 40 air tested: cast iron
�
❑Water Connection/Disconnect/Repair($50.00/Per Stub) �
Pipe size�i�icl�es;material C 9iX1p,cSchd 40 air tested; copper
❑ Water Availabilit,y For Future Hook-l;p to W'ater(550.00) $
Water Availabilitv Explanation:
Contractor iustalled line to insidc orhouse for luture hook-up.
This line will be inspected by ihe Public Works Depsrtmcnt.
Required Before Vl'ater Conncction Pennit is Issued:
1. lssue Water Meter c� Horn Permit �
2. Any Additional Connection Fecs Paid(If Applicablcj
Issuc Water Connection Permit: �
1. Collect Permit r'ee&lssue Water Connection Permit �
1. SUBTOTAL of Permit Requested: � O.o m
?. STATE SURCHARGE � 5.00
3. POSTAGE&HANDLING(Only on Mail-ln Applications) $ 2.00
4. T07'AL PERVIIT FEE(Add Lines l-3 .Abo��e) � 5.DO
ADDITIONAL INFORMATION-WATER METERS
■ WATER:VIETERS must be picked up and paid for at Orono City Hall,thcse are on a separate permit.
■ VVATER nI1�:TERS must be set and sealed b�� Orono VVater Department (952) 249-4600, upon
completion of ineter installation.
The undersigned hereby applies to the City of Orono far issuance of a Utility Pennit, agrees to do
all work in strict accordance with tlie ordinances of the City and the regulations of the State of
Minnesota;and certifies that al] statements made on this application are, true and correct.
Applicant: � � �c Datc: � /