HomeMy WebLinkAboutPLMBG 05-0431
Date Rec'd
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~. ~~~ ~~~ I PERMIT NO. () i..-" e 4-.711
3 Yellow Applicant . ,
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ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT z..- BLOCK I ADDITION
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OWNER
(Name)
(Phone)
(Address)
APPLICANT I . I/)(
(Name) c.c I' {' J I '1 l d (, 1-1 d, J L/; I ) t~
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(Address) t;'-IS)" - I ~Or 'j c:; t L./-
(Address)
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(Phone)
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(City)
(Zip Code)
(Contact Person)
(Phone)
APPLICANT SIGNATURE
DATE
S- -Ie Os-
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain Water Softner
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (lor 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Hl'Irkflow Assembly Test
Bar Sink C T awn Sprfiikler
Water Closet (Toilet) -Other
APPLICANT PLEASE COMPLETE BELOW
FEE SCHEDULE
Industrial. Commercial & Multi-family 1% of job cost with a $39.50 minimum
Residential, New One & Two-Family $99.50
Residential. Additions & Alterations $39.50
Building Permit # 0 S, (; #- J /
Estimated Cost $
(Office lJse Only)
PLUMBING PERMIT FEE $
STATE SURCHARGE $
TOTAL PERMIT FEE $
31SU
.50
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This Application Becomes Your Building Permit When Approved
Building Official
Date
Paid -f't1. t/V
Date __
6./(, -(/1-
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
16200 Eagle Creek Ave., S.E., Prior Lake, MN 55372-1714