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� � CITY OF ORONO * 2 0 1 6 - 0 PJ 3 3 3 * <br /> 2750 KELLEY PARKWAY DATE ISSUED: 04/OS/2016 <br /> ORONO,MN 55356- <br /> (952) 249-4600 FAX: (952) 249-4616 <br /> ADDRESS : 3 I 88 NORTH SHORE DR <br /> PIN : 09-117-23-32-0011 <br /> LEGAL DESC : CRYSTAL BAY PARK <br /> : LOT 000 BLOCK 004 <br /> PERMIT TYPE : SEWER&WATER <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : DISCONNECTION <br /> NOTE: SEWER AND WATER DISCONNECT <br /> APPLICANT SEWERCONNECT/DISCONNECT/REPAIR 50.00 <br /> WATER CONNECT/DISCONNECT/REPAIR 50.00 <br /> DSM CUSTOM CONSTRUCTION,INC. STATE SURCHARGE SEWER&WATER 1.00 <br /> 11110 196TH AVE NW <br /> ELK RIVER, MN 55330 TOTAL 101.00 <br /> (612)719-2724 Payment(s) <br /> CREDIT CARD 0444 101.00 <br /> OWNER <br /> RLJCINSKI,MICHEAL&HOLLY <br /> 3188 NORTH SHORE DR <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 graut permission for additional or related work wh ich requires separate <br /> permits. All provisions of laws and ordinances goveming this type 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 afrer�ork has commenced. <br /> The applicant is responsible for assuring all required inspections are <br /> requested in conformance with the State Building Code.This permit may be <br /> revoked at any time for due cause. <br /> ��� ,� L/ l�`�/t-<L�/� — �` / _ <br /> � � <br /> Applicant Permitee Signatur Date Issued B ignature Date <br />