HomeMy WebLinkAbout2013-00187 - sewer disconnect CITY OF ORONO * z p� 1 3 - 0 0 1 B 7 *
2750 KELLEY PARKWAY DATE ISSUED: 03/2U2013
ORONO,MN 55356-
(952 249-4600 FAX: (952) 249-4616
ADDRESS : 1535 MINNIE AVE
PIN : 08-117-23-33-0065
LEGAL DESC : HICKORY HILL
: LOT 005 BLOCK 000
PERMIT TYPE : SEWER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DISCONNECTION
NOTE: SEWER DISCONNECT
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
WESTONKA SEWER&WATER STATE SURCHARGE SEWER&WATER 5.00
6501 CO.RD 15
MOUND,MN 55364 TOTAL 55.00
(952)472-4959 PAID WITH CC# 7464
Minnesota State License#: 1804
OWNER
LLC,LANDSOURCE
550 25TH AVE N
ST CLOUD,MN 56303-
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 goveming 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 constsuction 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 wi e te Building Code.This permit may be
revoked at an�' for due a
.-� � � ��( � ( �� 2/�
Ap 'cant Permitee ignature Date Issue y Signature Date
SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE.
�___� F ClT USE OPILX ` �/
�i�1,IO��1 City of Orono DateReceivedc���f, ,,,,,_ Pern�it# ����""
P.O.Box 66
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i ' 2750 Kelley Pazkway ❑In-House SAC DeteAmlrxatian Form Completed '
�y ,�; Crystal Bay,MN 55323
`"�,�K{�xo�4G� (952)249-4600 Apprc�v�dBy(��'Required):
_..._--,
CITY OF ORONO-SEWER& WATER/GENERAL PERMIT
(*Note:Some permits may require approval by the Building O�cial and/or Public Works Department*)
(ALL PERMITS- Mav be subiect to further review and mav not be issued when the aoolication is receivedl
GENERAL 1NF(}RMATIUN '
l. 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. Permit 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 permit 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 A 1 � .
[�ReJsidential(May Require Approval) ❑ Commercial(Approval Required)
❑ New Connection ❑Additional Connection ❑Re-Connection ❑ Repairs '�Disconnect
❑ Water Availability Connection For Future Hook-Up to Water
7ob �ite f Qwner Tnformatzon:
' r
Site Address: � J ���i ✓1►'l /� � t
Owner: Mailing Address:
City: Zip:
Home Phone: Alternate Phone:
Gontractor Infarmation:
Contractor: �5����� S/�J Contact Person: ��� ��l C'�`�` �
Address: �����- /�`• (� State License#: �� �% �'�
City: (���t�1� Zip: ��6�Expiration Date:
Phone: ��'y7�-��� Alternate Phone: �/l�- �y� �T7��
❑ SAC Charge(2013 Rate=$2,435.00) $
(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)
�ewer Connection/ isconnec Repair($50.00/Per Stub) $
Pipe size in , erial 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 Exalanation:
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
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $
' ADDITIONAL'INFORMATI�N-WATER METERS
■ WATER METERS must be picked up and paid for at Orono City Hall,these are on a senarate 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 e City and the regulations of the State of
Minnesota, and certifies th�all statements mad n thi ication are,true and correct.
A licant: Date: ���� .J
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