HomeMy WebLinkAbout2012-00542 - sewer � � CITY OF ORONO * Z 0 1 2 — 0 fd 5 4 2 *
2750 KELLEY PARKWAY DATE ISSUED: 06/15/2012
ORONO,MN 55356-
(952)249-4600 FAX: (952)249-4616
ADDRESS : 495 OXFORD RD
PIN : OS-117-23-41-0011
LEGAL DESC : STIELOWS ADDN
: LOT 003 BLOCK 001
PERMIT TYPE : SEWER
PROPERTY TYPE : RESIDENTIAL
CONSTRUCTION TYPE : DISCONNECTION
APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00
MARK BENDICKSON,INC. STATE SURCHARGE SEWER&WATER 5.00
1501 HiJNTER DR TOTAL 55.00
WAYZATA,MN 55391-
(612)695-8072
OWNER
SAMPLE,MIKE&ANNE
1449 BAY RIDGE RD
WAYZATA,MN 55391-
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 dces
not grant permission for additional or related work which requires sepazate
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 respo�sible for assuring all required inspections are
reque d in conf rm with the State Building Code.This permit may be
revok a any ti fo due caus .
/ / / /
pplic rmitee S D Issue y � ature te
EPARATE PERMITS REQUIRED FOR WORK OTHE N DESCRIBED ABO
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�,�0�� City of Orono IZateRecetued. ` Perniit�#
P.O.Box 66 � �
2750 Kelley Parkway [�In-Hfluse SA�,Detecnrinatic�r►Form Completed '
� ,,, � Crystal Bay,MN 55323
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CITY OF ORONO—SEWER& WATER/GENERAL PERMIT
(*Note:Some permits may require approval by the Building Official and/or Public Works Deparhnent*)
(ALL PERMITS- Mav be subiect to further review and mav not be issued when the aoolication is received)
GENERAL INFORMATTON " �'
1. You may apply for urility pernuts 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 permit card.
4. Work must not begin unless the permit card is available on the job site.
5. Urility connection pernuts 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 pemut 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 PER�VIIT i
' (Check A11 That A 1
�esidential(May Require Approval) ❑ Commercial(Approval Required)
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❑ New Connection ❑Additional Connection ❑Re-Connection ❑Repairs �Disconnect
❑ Water Availability Connecrion For Future Hook-Up to Water V
Job Site/Owner Information:
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Srte Address: � t,� �� � � /�-�t - � K-
Owner: //// G� h � e Mailing Address: `Z��� d��(f�'. �S
City: d��� Zi S�'��� ��c
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Home Phone: Alternate Phone:
Contractor Information:
Contractar: /I I�'2(L s- ��C�Q'xc,Contact Person: /!�l.A�� l���14�'SZJGU
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Address: `S"U l f�`�u�- �iLfc.L State License#:
Gvay?sr�'t
City. Zip:�3R � Expiration Date:
Phone: �O�Z '(��!S'���?2- Alternate Phone:
❑ SAC Charge(2012 Rate=$2,365.00) $
(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)
�] Sewer Connectio /Disconnect/ epair($50.00/Per Stub) $
Pipe size inc , 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 Ezplanation:
Contractor installed line to inside of house for future hook-up.
This line will be inspected by the Public Works Department.
Rectuired 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 Applicarions) $ 2.00
4. TOTAL PERMIT FEE(Add Lines 1-3 Above) $
ADDITIONAT;'INFORMA'TIQN-W1�TER METERS
■ WATER METERS must be picked up and paid for at Orono City Hall,these are on a s�arate 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 statements made on this application are,true and correct.
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Applicant: ' Date:
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