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2014-01211 - sewer/water connection
� � CITY OF ORONO * Z 0 1 4 - 0 1 2 1 1 * 2750 KELLEY PARKWAY DATE ISSUED: 10/20/2014 ORONO, MN 55356- (952) 249-4600 FAX: (952) 249-4616 ADDRESS : 3320 NAVARRE LA PIN : 17-117-23-44-0059 LEGAL DESC : WILEYS NAVARRE ADDN LAKE MTKA : LOT 001 BLOCK 000 PERMIT TYPE : SEWER&WATER PROPERTY TYPE : RESIDENTIAL CONSTRUCTION TYPE : CONNECTION NOTE: SEWER AND WATER CONNECTION APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00 WATER CONNECT/DISCONNECT/REPAIR 50.00 GROTH SEWER&WATER STATE SURCHARGE SEWER&WATER 5.00 77S TOWER DRIVE HAMEL,MN 55340- TOTAL 105.00 (763)478-6712 Payment(s) CHECK 105.00 OWNER CUBE INC. 4825 HANOVER ROAD MOUND,MN 55364- AGREEMENT AND SWORN STATEMENT The work for which this pertnit 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 separate 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 conswction 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 aRer 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 revoked at any time for due cause. i � � � �� � y Applicant Permitee Signature Date Issued y Signature Date � �. -- t FO CITY U � ONLY j.-,���`�y C1Yy of Orono Date Receive mut# �/ 1` � �j� P.O.Box 66 + �� '' 2750 Kelley Parkway ❑In-House SAC Determ nation Form Completed ���\E '� •nl'' Crystal Bay,MN 55323 � � '�'� �� (952)249-4600/Fax(952)249-4616 Approved By(If Required): � ,;, � CITY OF ORONO- SEWER& WATER/ GENERAL PERMIT (*Note:Some permiu may require approval by the Building Official and/or Public N%orks Department*) (ALL PERMITS- Ma��be subiect to further revien and mav not be issued when the application is received) GENERAL 1NFORMATION 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. Permit cards will be sent by return mail within 2 business days. 3. Permits are not valid unril 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 ly) ❑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 Informa�ion: , ._ -' ' , . Site Address: ` � ��...� ..: �-f��� �;��L 2`� �. � Owner:� ���� � Mailing Address: City: Zip: Home Phone: Alternate Phone: Contractor Information: _.�--' � .../;�r ' Contractor: � � ��-� l.� � � ��� Contact Person: ,- � � ., � Address: � ;� S �� ��- � e License#: Ci �. ' �Uv� Zi � ��-y�C�,xpiration Date: tY: p: / , Phon�,� � � ��- �( � � ��� Alternate Phone: .r � ` DETERMINING PERMIT FEES ❑ SAC Charge(2014 Rate=$2,485.00) $ (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) --_._ ___._ — Se,,,�r C�o�nnectioq!-Disconnect/Repair($50.00/Per Stub) $ � �� � �) 'T�_�________.___ Pipe s�ze inches;material Schd 40 air tested; cast iron ��___, � �. �� �'Water Co/ nnection/ sconnect/Repair($50.00/Per Stub) $ � Pipe size-' mches;material Schd 40 air tested; copper ❑Water Availabilit�-For Future Hook-tip to Water($50.00) $ Water Availabiliri�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: 1. 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 1NFORMATION—WATER METERS ■ WATER METERS must be picked up and paid for at Orono City Hall,these are on a separate permit. ■ WATER METERS must be set and sealed by Orono V�ater Department (952) 249-4600, upon completion of ineter installation. The undersigned hereby applies to the City of Orono for issuance of a Utiliry 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. � .� � ; � � `" f /�/' C - � �-' Applicant: �����C/ Date: � ' � � � . , , . _ , �� a..� ' ,� ��`. p` 7 5� �`*; �. � � . ��: ,. � .. -� � � �� ` � � � � � �; � � � Y�,, i �,� 4� �` � ,�+� " � :.� � M �� " � - � ` � ;���� #9B'�.� . �M, :�,�4 } � . � � f �• ' � .. „ �.m � � �°*- c �y #i � �`' �_ ,�. �. � y "�1..� . ., �i.:en��� , y�:t - �a�;:`S' f��,r,�,� 3�.. . . „ F �' ., : � � '�. �'�` . . � � a - ��.� i .' � � � � . _ ; # .. � �.. r �F ,.�. �� . , :. a� h,x'+ ��� ._. �.� �. �. b� � �.�1F ,. �: , y�. � � � .r >�� -�. ,. x„� . .. �1,� � �� �mw$ 5*; � - � , �,y ,. . 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Cail for the next inspection 24 hours in advance. (952) 249-46�� OwnedContractor on site: Inspector. �y White Copyllnspector's File Canary CopylSite Notice