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` `' CITY OF ORONO * z 0 1 z — 0 0 e 0 1 * <br /> 2750 KELLEY PARKWAY DATE ISSUED: 09/19/2012 <br /> ORONO, MN 55356- <br /> (952) 249-4600 FAX: (952) 249-4616 <br /> ADDRESS : 1095 FERNDALE RD W <br /> PIN : 02-117-23-43-0023 <br /> LEGAL DESC : NORTH SHORE COTTAGE ACRES LAKE <br /> : LOT 009 BLOCK 000 <br /> PERMIT TYPE : SEWER <br /> PROPERTY TYPE : RESIDENT[AL <br /> CONSTRUCTION TYPE : DISCONNECTION <br /> NOTE: SEWER DISCONNEC I' <br /> APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00 <br /> BOHN WELL DRILLING CO. STATE SURCHARGE SEWER& WATER 5.00 <br /> 18190 DAIRY LANE TOTAL 55.00 <br /> JORDAN, MN 55352- <br /> (952)445-4809 <br /> Minnesota State License#: 1043 <br /> OWNER <br /> FOX, B& K <br /> 1095 FERNDALE RD W <br /> WAYZATA, MN 55391- <br /> AGREEMENT AND SWORN STATEMENT <br /> The w•ork for which this permit is issued shall be performed accordinb 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 /> no[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 compied with whether or not specitied herein.This permit will <br /> expire and become null and void if construction authorized is not <br /> commenced within l80 days of the date of issuance,or if construction is <br /> suspended for a period of 180 days at any time after work has commenced. <br /> The applicant is responsible for assuring all required inspections are <br /> requested in conYormance wi[h the State Building Code.This permit may be <br /> revoked at any[ime for due cause. <br /> C��c�d) 9� ao �� a � �� 9, ao , , <br /> Applicant Permilee Signature Date Issu By Signature Date <br /> SEPARATE PERMITS REQUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. <br />