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CITY OF ORONO * 2 0 1 5 - 0 0 5 0 4 * <br /> 2750 KELLEY PARKWAY DATE ISSUED: 04/29/2015 <br /> `' ORONO, MN 55356- <br /> � 952 249-4600 FAX: 952 249-4616 <br /> ADDRESS : 1340 FOX ST <br /> pi� : 02-117-23-31-0019 <br /> LEGAL DESC : MINNETONKA BLUFFS <br /> : LOT 000 BLOCK 014 <br /> PERMIT TYPE : SEWER <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : DISCONNECTION <br /> NOTE: DISCONNECT ONLY-NO SAC <br /> APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00 <br /> STATE SURCHARGE SEWER&WATER 5.00 <br /> COPPIN WATER&SEWER TOTAL 55.00 <br /> 864 QUAIL PKWY Payment(s) <br /> WATERTOWN, MN 55388- CHECK 4418 55.00 <br /> Minnesota State License#: SW-57329MR <br /> OWNER <br /> Chamberlain Capital LLC <br /> 11578 CAHMBERLAIN COURT <br /> EDEN PRAIRIE, MN 55344- <br /> AGREEMENT AND SWORN STATEMENT <br /> The work for which this permit is 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 separa[e <br /> permits. All provisions of laws and ordinances governing this type of work <br /> shall be compied with whether or not specified herein.This permi[will <br /> expire and become null and void if construction au[horized is not <br /> commenced within 180 days of the date of issuance,or if construction is <br /> suspended for a period of l80 days at any time after work has commenced. <br /> The applicant is responsible for assuring all required inspections are <br /> requested in conformance with[he State Building Code.This permit may be <br /> revoked a[any time for due cause. <br /> �`, <br /> . � i._( - � � � �t��_ �, � ��'"Y�C.��) �{ � a � � <br /> pp icant Permitee Signature Date Issued B�ature Date <br />