HomeMy WebLinkAbout2005-P09255 - sewer disconnect ` � PERMIT
CITY OF ORONO Permit Number:
2750 Kelley Parkway- PO Box 66 P09255
Crystal Bay, Minnesota 55323 Permit Type: Sewer and Water Permit
(952)249-4600 Date Issued: l0/4/2005
SITE ADDRESS: 4203 North Shore Dr Unit#
Mound,MN 55364
P��� 07-117-23-43-0008
DESCRIPTION:
Proposed Use: Residenrial
Permit Class: General
Permit Type: Sewer and Water Permit Pernrit Sub-type(s): Sewer Disconnect
DETAILS:
Approved per resolution#:
Separate permits required:
NOTICES/REMARKS:
FEE SUMMARY: Permit Fee: $ 35.00 Valuation: $ 0.00
State Surcharge Fee: $ 0.50
TOTAL FEE: $35.50
APPLICANT: Don Wayne Excavating OWNER: JeffGustafson
4960 Co.Rd. 10 E 4420 Shoreline Dr
Chaska,MN 55318 Spring Pazk,MN 55384
THE UNDERSIGNED HEREBY REQUESTS PBRMISSION TO MAKE THE REAL IMPROVEMENTS SPECIFIED
AND AGREES TO DO ALL WORK IN STRICT COMPLIANCE WITH ALL CITY OF ORONO ORDINANCES AND STATE OF
MINNESO BUILDING CODE REQUIREMENTS.
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AP C PE E SIGNATURE ISSUED BY SIGNATURE
Copies: 1-File(SignaturesRequired), 1-Applicant, 1-Monthly Reports, 1-Assessing,(If Septic, 1-Sepric) Page 1
FOR CITY USE ONLY
4�,�` City of Orono Date Received: Permit#
`r P.O.Box 66
�a�..,,,, O 27�0 Kelley Parkway ❑Tn-House SAC Determination Form Completed
,��'� �; `-` Crystal Bay,MN 55323
��^����;�.�o`� (9�2)249-4600 Approved By(If Required):
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CITY OF ORONO- SEWER& WATER/ GENERAL PERMIT
(*�Iote:Some permits may require approval by the Building Official and/or Public Works Department*)
(.4LL PERMITS- Mav be subiect to further review and mav not be issued when the npnlication 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 haiidling 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 must not begin unless the peinut 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 requu�ements.
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)
1
❑ New Connection ❑Additional Connection ❑Re-Connection ❑ Repairs �isconnect
Job Site/ Owner Information:
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Site Address: � J > -� J� � � �T�2� �
Owner: ��f��� �� ��V •>P��� Mailing Address: �`� �v ��'��`����-�'"R' ��
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City: Zip: �S 3�7 "
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Home Phone: Alten�ate Phone: � �j !°2 �6 � "D 4���
Contractor Information:
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Contractor: �d'`' w�I��� � �"` � Contact Person: ����� � Y`�
Address: State License #: � ���
City: Zip: Expiration Date:
Phone: �l�- ���� � � � �� Altenlate Phone:
DETERMINING PERMIT FEES
❑ SAC Charge(2005 Rate=$1,450.00) $
(SAC Charge must accompany all se�ver permit applications unless prepaid)
(Orono City Staff can deternune if applicable)
(If not prepaid,a sewe nection permit will not be issued) �
Sewer Connection/ isconn t/Repair($35.00/Per Stub) $ �
Pipe size inch ; ial Schd 40 air tested; cast iron
��ater Connection/Disconnect/Repair($35.00/Per Stub) $
Pipe size inches;material Schd 40 air tested; copper
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1. SUBTOTAL of Permit Requested: $ �>
2. STATE SURCHARGE $ .�0
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3. POSTAGE&HANDLING(Only on Mail-In Applications) $ 1.50
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4. TOTAL PERMIT FEE (Add Lines 1-3 Above) � ?~� �_
ADDITIONAL INFORMATION—WATER METERS
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■ 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.
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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 cer�fies that all state nts made on this application are, true and correct.
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Applicant: Date: ''� �j
D iE TIME �
CITY OF ORONO ��C��s CALLED IN UI �
INSPECTION NO�E SCHEDULED �/� �' 3-�� �
�v�PERMIT N0. ��� COMPLETED � '��S� � � J C�
DDRESS Q'� ^ �'` ' �
OWNER CONTR...,,��CLXY)�` G�� �`"Y'�
TELEPHONE N0. �`��' �+ ��' �%�'�1`-Y
� DESCRIPTION_�P��-r ��-�t,�(,>
� 01 FOOTING 11 MECHANICAL RI 18 EXCAV/GRADING/FILLING
Q 02 FRAMING 13 MECHANICAL FINAL 19 LAKESHORE/WETLANDS
y 03 INSULATION 24/25 WOOD BURNER/FIREPLACE 34 TREE REMOVAL
Z04 WALL BD. 12 WAT ppK-UQ 17 SITE INSPECTION
Q OS FINAL SE��,}100K-UP� 06 PROGRESS
� 07 DEMO-SITE 27 SEPTIC MAINT. 21 COMPLAINT
� 07 DEMO-FINAL 15 SEPTIC INSTALL. 22 FOLLOW-UP
= 09 PLUMBING RI 23 SEPTIC FINAL 35 HARD COVER REMOVAL
J 10 PLUMBING FINAL , / 36 FOUNDATION/REMOVAL
� OWNER/CONTRACTOR TO MEET YOU:_YES�NO
� COMMENTS:
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W� �Q WORK SATISFACTORY:PROCEED ❑ PROJECT COMPLETE
W ❑CORRECT WORK&PROCEED ❑ ISSUE CERTIFICATE OF OCCUPANCY
� ❑ CORRECT WORK,CALL FOR REINSPECTION TEMPORARY
V BEFORECOVERING PERMANENT
❑CORRECT UNSAFE CONDITION WITHIN HOURS. �� pH0T0 TAKEN
INSPECTOR WILL RETURN ❑ CITATION ISSUED
❑STOP ORDER POSTED.CALL INSPECTOR
❑ INSPECTION REQUIRED.CALL TO ARRANGE ACCESS.
Call for the next inspection 24 hours in advance. �95Z� Z49-460�
OwnerlContractor on sit • �
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Inspector. .,��a �
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