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CITY OF ORONO * 2 0 1 5 - 0 1 z 1 2 * <br /> � 2750 KELLEY PARKWAY DATE ISSUED: 09/2U2015 <br />� ORONO, MN 55356- <br /> 952 249-4600 FAX: 952 249-4616 <br /> ADDRESS : 2523 KELLY AVE <br /> PIN : 20-117-23-12-0039 <br /> LEGAL DESC : REG.LAND SURVEY NO. 1428 <br /> : LOT 000 BLOCK 000 <br /> PERMIT TYPE : PLUMBING(<$500) <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : WATER SOFTENER <br /> APPLICANT PLUMBING FIXTURE FEE(<$500) 15.00 <br /> CHAMPION PLUMBING LLC STATE SURCHARGE PLBG(<$500) 1.00 <br /> 3670 DODD ROAD-SUITE 100 MAIL-IN FEE 2.00 <br /> EAGAN,MN 55123- TOTAL 18.00 <br /> � Payment(s) <br /> CHECK 31670 18.00 <br /> OWNER <br /> SACHS,BEN <br /> 2523 KELLY AVE <br /> EXCELSIOR,MN 55331- <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 Ciry approvals,and the <br /> State Building Code. This permit is for only the work described and dces <br /> not gant 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 specified herein.This permit will <br /> expire and become null and void if construction suthorized 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 n_ <br /> revoked at any time for due cause. 6� <br /> Q l � �U�� ��--��`1 �CJ � / Z l / 1 <br /> Applicant Permitee Signature Date Issued By Signatur Date <br />