HomeMy WebLinkAbout2016-01071 - sewer connection - CITY OF ORONO * 2 0 1 6 - 0 1 0 7 1 *
y 2750 KELLEY PARKWAY DATE ISSUED: 08/3U2016
ORONO,MN 55356-
(952)249-4600 FAX: (952) 249-4616
ADDRESS : 940 NORTH ARM DR
PIN : 07-117-23-11-0014
LEGAL DESC : PIRATES COVE
: LOT O10 BLOCK 001
PERMIT TYPE : SEWER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : CONNECTION
NOTE: SEWER CONNECTION
APPLICANT SEWERCONNECT/DISCONNECT/REPAIR 50.00
STATE SURCHARGE SEWER&WATER 1.00
WESTONKA SEWER&WATER TOTAL 51.00
6501 CO.RD 15 Payment(s)
MOLJND,MN 55364 CREDIT CARD 1685 51.00
(952)472-4959
Minnesota State License#:BUIL-1804
OW1�1ER
OLSHANSKY,ROMAN
76 KINGSVIEW LANE N
PLYMOUTH,MN 55447-
AGREEMENT AND SWORN STATEME1vT
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 pertnit is for only the work described and does
no[grant permission for additional or related work which requires separate
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 a required inspections are
requested in conformance with the Stat uilding Code.This permit may be
revoked at ' e for due se ^ /f 9�
� �� l� ��-E��,VIY
I�-� � � � �1 �
Applicant Permitee Signature Date Issued By S�ig�r►ature Date
.
• �_.—_..` I U��O1�LY -7
����0�� C1tyOfOYono DateReceived: Pe�mit# /� ���/ �
1 `, P.O.Box 66
� �1 ; 2750 Kelley Parkway ❑In-Hoase SAC Determinallon Form Completed
�y\t� y.�� Crystal Bay,MN 55323
� (952)249-4600/Fax(952)249-4616 Approved By(Il'Royuired):
\�\Ais�io�'�
--_--�•
CITY OF ORONO—SEWER& WATER/GENERAL PERMIT
(*Note:Some permits may requ've approval by the Building Official and/or Public Works Departrnent')
(ALL PERMTI'S- Mav be subiect to further review and mav not be issued when the auolication is rcceivedl
GENERAI,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. 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. Urility 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 ezpress
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+�our notice required.
TYP�OF PER�vIIT
Check All That A i
�Residential(May Require Approval) ❑Commercial(Approval Required)
� �
New Connecrion ❑Additiona]Connection ❑Re-Connection ❑Repairs ❑Disconnect
� ❑ Water Availability Connection For Future Hook-Up to Water
Job Site/Owner Ir�ormation:
Site Address: `l � ��0✓� 'J � �t� /n r
Owner: Mailing Address:
City: Zip:
Home Phone: Alternate Phone:
Contract�or Inforrnation:
,
Contractor: � ����''1 '�� Contact Person: i'4 �� Q��
Address: ���D� CO� _� �� State License#:
City: �C` Zip.�s�� Expiration Date:
Phone: C�� T �"�`���1� Alternate Phone: 1�1�2- 7��� ��7�
.
D�'I�ERIy'�Q�I�T�i'��MI�'FEES
❑ SAC Charge(2015 Rate=52,485.00) $
(SAC Charge must accompany all sewer permit applications unless prepaid)
(Orono City Staff can determine if applicable)
(If not prepaid,a sewer connection permit wilt not be issued)
�ewer Connect'on/Disconnect/Repair($50.00/Per Stub) $
Pipe size�inches;material_�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 Eaalanation:
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 Connecrion Permit:
1. Collect Permit Fee&Issue Water Connection Permit
1. SUBTOTAL of Permit Requested: $ .e/�� U v
2. STATE SURCHARGE $ 1.00
3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $ �` � �
ADDITIONAL INFORMATION-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 the City and the regulations of the State of
Minnesota, and certifies that all st tements made on this application are,true and correct.
C
� �r I �
Applicant: �-� Date: ;��
. ✓
' Q DATE TIME
CITY OF ORONO ALLED IN %��
INSPECTION N TI E SCHEDULED —
PERMIT NO. ����—DI Q�� CO PLETED '
ADDRESS 9`f"U ' ��
OWNER _ �� TELEPHQN�� / Q� � /
CONTRAc�R � l �'�
'' DESCRIPTION �-��� ��'���
� ❑ FOOTING ❑ DEMO-FINAL ❑ SEPTIC FINAL
Q ❑ POURED WALL ❑ PLUMBING RI ❑ EXCAV/GRADING/FILLIN(i
�Q ❑ FOUNDATION WATERPROOF ❑ PLUMBING FINAL ❑ TREE REMOVAL
Z ❑ RADON SLAB ❑ MECHANICAL RI ❑ SITE INSPECTION
Q ❑ FRAMING ❑ MECHANICAL FINAL ❑ RATED WALLS
� ❑ INSULATION ❑ WOOD BURNER/FIREPLACE ❑ COMPLAINT
� ❑ FINAL ❑ WATER HOOK-UP ❑ FOLLOW-UP
41 ❑ AS BUILT-SURVEY ❑ SEWER HOOK-UP ❑ FOUNDATION/REMOVAL
_
v ❑ DEMO-SITE ❑ SEPTIC INSTALL
? OMfNERICOKTRACTOR TO MEET Y�W:_YES_NO
� COMMENT'� �� ��� �i� �' 5��,�Zl
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� K SATISFACTORY:PROCEED /D�PROJECT COMPLETE
W ❑OORRECT YMORK a PROCEED � ❑ISSUE CERTIFICIITE OF OOCUPY�NCY
OO ❑CORRECT WOFtlC,CALL FOR REINSPECTION TEAAPORARY
V BEFORE COMERINO PERAAANENT
❑CORRECTUNSAFECONDIT10NWfTHIN H��• " pHpTOTAKEN
INSPECTOR WFLL RETURN
❑ TATION ISSUED
�STOP ORDER POSTED.CALL INSPECTOR
O INSPECTION REQUIRED.CALL TO ARRANf3E ACCESS.
CaY tor the next inspectfon 24 hours in advanoe. (952) 249-4600
OwnerlContractor on site: ., /�4�.,
inspector.
Whits CopyAnspeeto�'s Fil� Canary CoprlSib Noda
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