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� t CITY OF ORONO * z p� 1 3 - 0 1 2 0 6 * <br /> 2750 KELLEY PARKWAY UATE �SSUED: 1U13/2013 <br /> ORONO, MN 55356- <br /> (952) 249-4600 FAX: (952) 249-4616 <br /> ADDRESS : 2605 KELLY AVE <br /> PIN : 20-117-23-14-0022 <br /> LEGAL DESC : TOWNS[TE OF LANGDON PARK <br /> : LOT 005 BLOCK 005 <br /> PERMIT TYPE : SEWER & WATER <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : DISCONNGCTION <br /> N07�E: �L'n"I�ER& SI;WF=,R DISCONNGCTION <br /> APPLICANT SEWER CONNECT/DISCONNECT/REPAIR 50.00 <br /> BURNS EXCAVATING, INC. WATER CONNECT/DISCONNECT/REPAIR 50.00 <br /> 3470 CO. RD 21 <br /> MAYER, MN 55360- STATE SURCHARGE SEWER& WATER 5.00 <br /> (612)685-4303 TOTAL 105.00 <br /> Minnesota SCate License#: 1888 <br /> OWNER <br /> WINE, SC07"1�&JILL <br /> 2587 KELLY AVE <br /> EXCF.LSIOR, MN 55331- <br /> AGREEMENT AND SWORN STATEMENT <br /> The work ibr which this permit is issued shall be perfi�nned according to <br /> the approved plans and specitications,applicable City approvals,and thc <br /> State Building Code. This pemiit is for only the work described and docs <br /> not�rant permission for additional or related work which requires scparate <br /> permits. All provisions of laws and ordinances governing this rype of���ork <br /> shall be compied with whcUicr or not specitied herein.This permit���ill <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 /> I�he applicant is responsible for assuring all required inspections are <br /> requcsted in conformance with the State Building Code.This permit may bc <br /> revoked at a�ry time for due cause. <br /> -_. l� � l � ��� �'-� ���� ��� .�C��L_ �/i /� i ,� <br /> Applicant Permitee Signature Date Issu� By Signature Date <br /> SEPARATE PERMITS RF,QUIRED FOR WORK OTHER THAN DESCRIBED ABOVE. <br />