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� "' CITY OF ORONO PERM[T NO.: 2oli-oo4ss <br /> 2750 KELLEY PARKWAY <br /> � ORONO, MN 55356- DATE [ssuEn: 06/22/2011 <br /> 952 249-4600 FAX: 952 249-4616 <br /> ADDRESS : 4250 FOREST LAKE DR <br /> PIN : 07-117-23-12-0022 <br /> LEGAL DESC : FOREST ARMS COUNTRY CLUB ADDN <br /> : LOT 000 BLOCK 002 <br /> PERMIT TYPE : MINOR ALTERATIONS <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : ROOFING-ASPHALT <br /> ACTIVITY : O/S BUILDINC -LINDEFINED <br /> VALUATION : $ 9,700.00 <br /> NOTE: 1'EAK OFF REROOF-ASPHALT <br /> APPLICANT PERMIT FEE SCHEDULE 191.75 <br /> GIERTSEN COMPANY STATE SURCHARGE(VALUATION) 4.85 <br /> 8385 IOTH AVE N <br /> GOLDEN VALLEY, MN 55427- TOTAL 196.60 <br /> (763)546-1300 <br /> Minnesota State License#: 1796 <br /> OWNER <br /> ETAL, ROBERT DONGOSKE <br /> 4250 FOREST LAKE DR <br /> MOUND, MN 55364 <br /> AGREEMENT AND SWORN STATEMENT <br /> The work for which this permit fs issued shall be performed according to <br /> the approved plans and specifications,applicable City approvals,and the <br /> State Building Code. This permit is for only the work described and does <br /> not grant permission for additional or related work which requires separate <br /> permits. All provisions of laws and ordinances governing this type of work <br /> shall be compicd with whether or not specified herein.This permit will <br /> expire and become null and void if c tru tion authorized is not <br /> commenced within 180 days of t date of ssuance,or if construction is <br /> suspended for a period of 180 ys at any ime after work has commenced. <br /> The applicant is responsible for ssuring II required inspections are <br /> requcste in c ' form c �with e State uilding Code.This permit may be <br /> revqKed at an time o d e c se. , � <br /> . � <br /> � � l l � �,l{.� �i ��-�� �� <br /> Applicant Permitee Signature Date Issue y Signature Date <br /> SEPARATE PERM[TS REQU[RED FOR WORK OTHER THAN DESCRIBED ABOVE. <br />