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� ! CITY OF ORONO * 2 0 1 4 - PJ PJ 5 5 8 * <br /> 2750 KCLLEY NARKWAY DATE ISSUED: 06/04/2014 <br /> ORONO, MN 55356- <br /> (952) 249-4600 FAX: (952) 249-4616 <br /> ADDRF,SS : 2650 COUN�RYSIDE DR W <br /> PIN : 04-117-23-12-0014 <br /> LEGAL DESC : OLD CRYSTAL BAY ROAD AUDN <br /> : LOT 006 BLOCK 002 <br /> PERMIT TYPE : MECHANICAL(> $500) <br /> PROPERTY TYPE : RESIDENTIAL <br /> CONSTRUCTION TYPE : GAS LINE ONLY <br /> VALUATION : $ 1,900.00 <br /> NOTE: GASLI?�[:TO POOI,1II?n"Il?IZ AND I�IR►i"I�/1[3I,F, <br /> APPLICANT MECHANICAL 50.00 <br /> STATE SURCHARGE MECH (VALUATION) 0.95 <br /> ME'I�RO GAS INS'I'ALLERS TOTAL 50.95 <br /> 685 141ST LANE N W Payment(s) <br /> ANDOVER, MN 55304 <br /> (763)754-7119 CHECK 14717 50.95 <br /> Minnesota State License#: mech-MB003162 <br /> OWNER <br /> JORGENSON, ROBERT <br /> 2650 COUNTRYSIDE DR W <br /> I,ONG LAKE, MN 55356 <br /> AGREEMENT AND SWORN STATEMENT <br /> l�he���ork for which this permit is issued shall be perfom�ed according to <br /> the approved plans and specifications,applicable City approvals,and the <br /> State Building Code. 'i'his pennit is for only the���ork descrihed and docs <br /> not�rant p�rmission for additional or related work which requires separate <br /> permits. AII provisions of laws and ordinances govcming this t}�pe of��ork <br /> shall be compied with whether or not specified hercin."I�his pennit will <br /> e�pire and become null and void if construction authurized is not <br /> commenced���ithin 180 days of the date of issuance,or if construction is <br /> suspended for a period of 180 days at any timc aftcr work has commenced. <br /> The applicant is responsible tbr assurina all required inspcetions are <br /> requested in conformance with the State I3uilding Code.This permit may be <br /> revoked at am tim for d cau �. <br /> � � ���� � � / � <br /> Ap cant Permitee Signature Date Issu� By Signature Date <br />