HomeMy WebLinkAbout2005-P09423 - sewer disconnect ' - ' PERMIT
CITY OF ORONO
2750 Kelley Parkway- PO Box 66 Permit Number: P09423
Crystal Bay, Minnesota 55323 Permit Type: Sewer and Water Pernut
(952) 249-4600 Date Issued:
11/15/2005
SITE ADDRESS: 3619 North Shore Dr Unit#
Wayzata,MN 55391
PID: 08-117-23-34-0010
DESCRIPTION:
Proposed Use: Residential
Permit Class: General
Permit Type:
Sewer and Water Permit Permit Sub-type(s): Sewer Disconnect
DETAILS:
Approved per resolution#:
Separate permits required:
NOTICES/REMARKS:
FEE SUMMARY: Pernut Fee: $ 35.00 valuation: $ 0.00
State Surcharge Fee: $ 0.50
TOTAL FEE: $ 35.50
APPLICANT: Larson Plumbing Inc. OWNER: Gary&Sandra Baron
3095 162nd Ln NW 4745 Yorktown Lane N
Andover,MN 55304 Plymouth,MN 55442
THE 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 STATE OF
MINNESOTA BUILDING CODE REQUIREMENTS.
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� APPLIC T ERMITEE SIGNATURE [SSLTED BY SIGNATURE
Copies: 1-File(SignaturesRequired), 1-Applicant, 1-MonthlyReports, 1-Assessing,(IfSeptic, 1-Septic) Page 1
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FOR CITY USE ONLY
,��� City of Orono Date Received: Permit# '
P.O.Bos 66
��;,.,,,, O 27�0 Kelley Parkway ❑Tn-House SAC Determination Form Completed
��'���;;� � Crystal Bay,MN 55323
����'��+-,�.�o` (952)249-4600 Approved By(If Required):
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CITY OF ORONO-SEWER& WATER/GENERAL PERMIT
(*;Vote:Some permits may require approval by the Building Official and/or Public Works Department*)
(ALL PERMITS- Mav be subiect to further review and mav�ot be issued when the annlication is received)
GENERAL 1NFORMATION
1. You may apply for utility peimits by mail or in person at the City offices.
2. Mailed in 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 pernut card.
4. Work inust not begin unless the peinut 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 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:
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Site Address: >tio-�i�-' ��'��`� i L�v� 1J��-
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Owner: ��'2� ���`'"i�`� Mailing Address:
City: C� "JZ-�-%wv Zip:
Home Phone: Alternate Phone:
Contractor Information:
Contractor: L/}{LS6� , `""`� �`�- Contact Person: �`�k `-"��'�
Address: �3 U�{S 1 b�n� 1.�� State License#: L�� 33�'� 1 ��
City: ������+`� Zip: �'�r� Expiration Date: 1��3� �0 5
Phone: �I�' 3 �l- `����fi Alternate Phone: �G� '� L�'��� �
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DETERMINING PERMIT FEES '
❑ SAC Charge(2005 Rate=�1,450.00) $
(SAC Charge must accompany all sewer pernut applications unless prepaid)
(Orono City Staff can determine if applicable)
(If not prepaid,a sewer connection permit will not be issued)
� Sewer Connection/ isconnect epair(�35.00/Per Stub) $ � � � �
Pipe size in ial Schd 40 air tested; cast ironJ
❑ Water Connection/Disconnect/Repair($35.00/Per Stub) $
Pipe size inches;material Schd 40 air tested; copper
1. SUBTOTAL of Permit 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 separate 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 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 statements made on this application are, true and correct.
Applicant:��/��''� Date: � � � S � �