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CITY OF ORONO * Z p� 1 4 - 0 PJ 2 8 4 * <br /> f l 2750 KELLEY PARKWAY DATE ISSUED: 04/07/2014 <br /> ORONO, MN 55356- <br /> (952 249-4600 FAX: (952) 249-4616 <br /> ADDRESS : 495 OXFORD RD <br /> PIN : OS-117-23-41-0011 <br /> LEGAL DESC : STIELOWS ADDN <br /> : LOT 003 BLOCK 001 <br /> PERMIT TYPE : MECHANICAL(> $500) <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : GAS LINE ONLY <br /> VALUATION : $ 700.00 <br /> NOTE: GASLINE FOR OUTDOOR GRILL <br /> APPLICANT MECHANICAL 50.00 <br /> METRO GAS INSTALLERS STATE SURCHARGE MECH(VALUATION) 0.35 <br /> 685 141ST LANE NW TOTAL 50.35 <br /> ANDOVER, MN 55304 Payment(s) <br /> (763)754-7119 CHECK 14600 50.35 <br /> Minnesota State License#: mech-MB003162 <br /> OWNER <br /> SAMPLE, MIKE&ANNE <br /> 1449 BAY WDGE RD <br /> WAYZATA, MN 55391- <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 sepazate <br /> permits. All provisions of laws and ordinances goveming this rype of work <br /> shall be compied with whether or not specified herein.This permit will <br /> expire and become null and void if construction authorized is not <br /> commenced within 180 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 aze <br /> requested in conformance with the State Building Code.This permit may be <br /> revoked at any time for due cause. <br /> / � /� <br /> Applicant Permitee Signature Date Issu By Signature Date <br />