HomeMy WebLinkAboutBuilding Permit 03-0569
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CITY OF PRIOR LAKE
~rparfmruf nf ~ltilMuy Jfusprdinu
ftrinal Permitted D Conditional C.O. Expires
This Certificate issued pursuant to the requirements of Section 307 of the Uniform Building Code certifying
that at the time of issuance this structure was in compliance with the various ordinances of the City of Prior
Lake regulating building construction or use. For the following:
Use Classification
SINGLE FAMHY
Bldg. Permit No.
01-0'if\Q
Occupancy Type
R3
Type Construction VN
Fire Zone N I A
Zoning District PTm
Lega! Description _ L4" R 1. ~1'ERL ING ADDITION
Owner of Building ~~
Contractor's Name & Address Mr.nONA T.n r.d~.~"T'R._
ROBERT D. HlJTCHINS "/ij [7
Building OffiCiall! (j/
Date: I :) - \ - 07, I
/
POST IN CONSPICUOUS PLACE
Site Address
14QS1 RTTJ.~TnE rTRrT~
7f\01 14'i1'1l ~1'. W. _ APPT.F VAU.FV 'i'i 114
City Planner
nON RVE
Date:
DATE TIME
CITY OF PRIOR LAKE C1-I'l-03
INSPECTION NOTICE SCHEDULED /1:00
ADDRESS 1 L\9. ~~ W..Uc....,..Vri (I.h-
OWNER CONTR.
PHONE NO. PERMIT NO. "3 -5~'t
o FOOTING o PLUMBING RI o EXtGRADtFlLLlNG
o FOUNDATION o MECH RI o COMPLAINT
o FRAMING o WATER HOOKUP o FIREPLACE RI
o INSULATION o SEWER HOOKUP o FIREPLACE FINAL
o FINAL )!(PLUMBING FINAL o GASLlNE AIR TST
o SITE INSPECTION o MECH FINAL 0
COMMENTS:
I. J~ AL~,.,.C' Q. pc,
2, T\.A.<.r--~. 'Oc<:t. "\Gool,,.--
:? f3u~ S.'lA~ 11I,,+ ";l.,...,J,-uY t. 1/1
o WORK SATISFACTORY, PROCEED
)cCORRECT ACTION AND PROCEED
o CORREfJ~' CALL FOR REINSPECTION BEFORE COVERING
Inspector: \r U ) Owner/Contr:
../
CALL 447-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
HaND"
~._._-_._"...__.__...~.___._____._.....,________.__..._____..._ .,. ,0, ...._.<..,.__~_________.._._..._
CITY OF PRIOR LAKE
INSPECTION NOTICE
ADDRESS /4 q t;{"(
OWNER
PHONE NO.
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
)!l FINAL
o SITE INSPECTION
SCHEDULED
lJ.i.1J SI',Q~
CONTR.
PERMIT NO.
o PLUMBING RI
o MECH Rl
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
COMMENTS:
-~A\...~~ ~l.
~- 0 ~f- ()
~
DATE TIME
IBot-or /:7(;
6>s - 6Co'7
o EXtGRADtFlLLING
o COMPLAINT
o FIREPLACE RI
o FIREPLACE FINAL
o GASLlNE AIR TST
o
~.Q
)twORK SATISFACTORY. PROCEED
o CORRECT ACTION AND PROCEED
o CORRE ~(~. CALL FOR REINSPECTION BEFORE COVERING
Inspector: J 1/ Owner/Contr:
CALL "7-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE.
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETY!
INSNOn
CITY OF PRIOR LAKE
INSPECTION NOTICE
DATE nilE
SCHEDULED
9-230'
ADDRESS /Ljq~3 HIIIs,Plt C'/
OWNER CONTR. /VI" to-It/
PHONE NO. PERMIT NO. (') -z, - 5"69
o FOOTING
o FOUNDATION
o FRAMING
o INSULATION
~L
o SITE INSPECTION
o PLUMBING RI
o MECH RI
o WATER HOOKUP
o SEWER HOOKUP
o PLUMBING FINAL
o MECH FINAL
~~ILUNG
o CO~NT
o FIREPLACE RI
o FIREPLACE FINAL
o GASUNE AIR TST
o
COMMENTS:
h N1 /.1-< - Icy[
L . /!:, )S,f'NI - ("J J(
~K SATISFACTORY, PROCEED
o CORRECT ACTION AND PROCEED
o CORRECT WORK, CALL FOR REINSPECTION BEFORE COVERING
Inspecto~~' - Owner/Contr:
CALL "7-9850 FOR THE NEXT INSPECTION 24 HOURS IN ADVANCE..
CODE REQUIREMENTS ARE FOR YOUR PERSONAL HEALTH & SAFETYI
1NSNCn"'
---"---,~~-"--_..-,,- ..-..-,-----.-"
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(Please ~~ or mint and si~ at bottom)
ADDRESS
C: --
CITY OF PRIOR LAKE BUILDING PERMIT,
TEMPORARY CERTIFICATE OF ZONING COMPLIANCE
AND UTILITY CONNECTION PERMIT
t, White File
2. Pink City
]. Yellow Applicant
Date ReL
t/.)5'3
I PERMITNOo03'_050~
I
I ZOlp/!)5"USO)
;LS--5'1l7"' v~.f
PID~" ..' '!.'-~
,
1Lf183 tltl!5/de a/ Jr
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!r!;--'~'.,._~:_-,-_,,:...~ _
....
LEGAL DE~C)UPTION (office use only)
LOT~~CK I ADDITION.
OWNER
(Name)
t11 ~fl....... ,U
(Address)
(Address)
? r..,ol
TYPE OF WORK
SJ-<R.lc'17
('l~c- J <
C",,-,7 -
(\..1 1..-...____
AJJ,' -t--' <.7"'-.
(Phone)7S;:~-43'~' 7fo(
(Phone) 9Sd..-4J';). - 7f,. c.) l
(Phone) f::,f~ -?o I - ~L (~ l(
11l,
r}cJe h.--.~
i:7
lEpeck ~orch ORe-Roofing
~ireplace OAddition DAlteration
PROJECTCOST/VALUE (excluding land) S (/ (", 6Cl:.J.
.Ii( N ew Construction
.lCt,Lower Level Finish
BUILDER ./l J)
(Name) /1.1 1'(.J?.-.; (
(Contact Name) T.....A.L
f Lt.. - J AS' l' t.-v...r 7.
ORe-Siding
i'vUtility Connection
~
"-
"'-
I hereby certify that I have furnished information on this application which is to the best of my knowledge true and correct. I also certify than am the owner or 1
authorized agent for the above-mentioned property and that all construction will conform to all existing state and local laws and will proceed in accordance with
submitted plans. I am aware that the building official can revoke this permit for just cause. Furthermore, I hereby agree that the city official or a designee may
enter up pro erty to perform needed inspections.
o Misc.
x
v
I Permit Valuation
I Permit Fee
1 Plan Check Fee
I State Surcharge
1 Penalty
I Plumbing Permit Fee
I Mechanical Permit Fee
I Sewer & Water Permit Fee
I Gas Fireplace Permit Fee
I
$
$
$
$
$
$
$
$
t'? 11., .II n I].{)() I
i"203.3"
IY3Z.Is>,
l'5~.oo'
I
I
I
I
I
100.00
100.0 D
3sSo
~,OO
This Application Becomes Your Building Permit When Approved
~ -1~ t/P';./a3
. Building Official Date
..51 I::J. l{
Contractor's License No.
t.{- r~-~o3
~"'-
~a.oo
1Z.7~.01J
,~"'o.oo
70,00
/2-00. () C
7oc, {) 0
IS"O().O"
This is to certify that the request in the above application and accompanying documents is in accordance with the City Zoning Ordinance and may proceed as requested. This document
~hen signed by the City Planner constitutes ~mporary Certificate of Zoning compliance and allows construction to commence. Before occupancy, a Certificate of Occupancy must be
"S~ngDi~ ~~~~~ ,f?~ ~o~~~
24 hour notice for all inspections (952) 44709850, tax (952) 447-4245
16200 Eagle Creek Avenue Prior Lake, MN 55372
1$
I $
I $
I $
I $
I :
I $ 1
I~ $C!; 9r,.c1' 03 1
I Re7feiJ' --0. ~(p~ I
Bv. I
(J
i1, f!.-f) 3. I b
I Park Support Fee
1 SAC
I
1
#
#
Water Meter Size 5/8";6
Pressure Reducer
I City SAC and WAC
, Water Tower Fee
I Builder's Deposit
1 Other
I TOTAL DUE
#
#
c..M-~ ~ ?$"
" ~,r ..,' oj
,...H",-,," )
I Paid
I Date
'Uf1. r ' ~/_
6.1/9
White - Building
,.....:ri'.,B~ EnaineerlnY;J
Pink - Planning
Th~ C"nlp. or lh.. l..k.. ('ounny
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
'-i/,!,d "
"f I" ,'<
, . ~ ~.--
, ,/'
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',.,f ,\.:' \ _"""'---......
APPLICATION RECEIVED
/1- /5--(":2,
, .. '. ,~,. ------
/
/0i /7;' ()::J;
:
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at:-
)' L/9'g~ /-1 ,-",1, ,'i J
-S '\', /" f ,,-.,{ {/
, ~ ,Y"cf.::!j,( (,~~~
Accepted
Denied
x
Accepted With Corrections
Reviewed By:
/YJ9-D
Date:
s- 30-0 ~
Comments: See Reverse Side for Additional Information!
See Attachments' 1) Grading PlaJ1, ?) Frosion Control Measures
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."
",
~~
White - Building
CanarY . Enaineering
C:Pink - Plannintb
fhf ("tnl!', of lhl' "_"l' COUnlrl
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
NAME OF APPLICANT
APPLICATION RECEIVED
.,..../ I
/ J / / I
'. 5' (
(;- / - - --
/
,
r :,,--
;.-.-
,
/"- , . ,- '
I >i /7//) ?>
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construction activity which is proposed at: -
) l./ (1 v-:) ;' /
I 0 -..J f.' j .' . ," / -<-
! ."_ I ~ I ! I /_/
Accepted
Denied
Accepted With Corrections
v
Reviewed By:
~
~'-p. ~
...
~
.&.~-
,(!.. --........,~
~
~,.- t7,.,t.
II
~
Date:
...1:) /3t:J ~ 'S
Comments:
j
A A/""'.,. ~ f u:.....J . .-4-. ('.
- ,- .
,,4.' o..tJJlj -4'~ 4-
cJ -
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."
~1
rWhite _ - Building:,
Canary - Engineering
Pink - Planning
Th!' ("!'nl!'r nf Ihr l.akr ('ountn'
BUILDING PERMIT APPLICATION DEPARTMENT CHECKLIST
m tl i~()-era
4-/5-03 / iiI/sloG
/ I f
The Building, Engineering, and Planning Departments have reviewed the building permit
application for construc~02l~/8;WhiCh iJ;ll; dr . ~
. ,- .-
NAME OF APPLICANT
APPLICATION RECEIVED
Accepted
Accepted With Corrections
~
Denied
~
Reviewed By:
~
~~ />
'-:;Z...u...l2P Date: 5/?6 ~:?
// ~,-,~ ~-~
Comments:
"The issuance or granting of a permit or approval of plans, specifications and
computations shall not be construed to be a permit for, or an approval of, any violation of
any of the provisions of this code or of any other ordinance of the jurisdiction. Permits
presuming to give authority to violate or cancel the provisions of this code or other
ordinances of the jurisdiction shall not be valid."
PRIOR LAKE
INSPECTION RECORD
SITE ADDRESS ~ U' '
NATURE OF WORK
USE OF BUILDING s..B....l> . .
PERMIT NO. _ DATE ISSUED ~, _
CONTRACTOR ~N.ILJ;>>N'" pHONE1:ll."'-fj61f1(
NOTE: THIS IS NOT A PERMIT FOR ANY OF THE INSPECTIONS BELOW
THE PERMIT IS BY SEPARATE DOCUMENT
DEPARTMENT OF
BUILDING AND INSPECTION
N,U
INSPECTOR
DATE
I FOOTING r' r ~ ...,....c::>1
, FOUNDATION (Prior to Backfill) I v"/;-Y/ I~, /].-1/'1
PLACE NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
ROUGH - INS
I-"" ~ ,/-~
f/l;V)
~
SEWER I WATER I SEPTIC
FRAMING
INSULATION
ELECTRICAL
PLUMBING
HEATING (if required)
FIREPLACE
GAS LINE AIR TEST
l ! '"
c.'Vi Ie,
'f ,>tf/7
iN't./-lo'3
I PLJ
I
I
~. F/1 PlY
'I .
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
l,57"I<<:J:tJ / (!JJ L7II#G/l.FIJ#S I I
FINALS~,
/1/
/ih
eo /
:> -/1\"
l/lf
,M'
45
'7 -.'3ir<17
7- '5>J V'7
GRADING (Prior to Sodding)
BUILDING
ELECTRICAL
PLUMBING
HEATING
DO NOT
/tJ.../ -q:J
/ZJ-/- Q3;
~
OCCUPY UNTIL ABtJE HAS
NOTICE
7' -/c5P
BEEN SIGNED
This card must be posted near an electrical service cabinet prior to rough-in inspections
and maintained until all inspections have been approved. On buildings and additions
where no service cabinet is available, card shall be Illaced near main entrance.
FOR ALL INSPECTIONS (952) 447-9850
CITY OF PRIOR LAKE
HEATING/AIR CONDITIONING/FIREPLACE PERMIl!
L:
, ,! ,': i I' ;._~~ I " ,!1
, J i))~ie ~{J 'f
.}I /I V B 2003 i
,'"", j".."..-
I. Pink File
2, Green City
3 , Yellow Applicant
l d y _~____'_"_~_"'____'_'__ . ___._.____
PERMIT NO.(J3_OI5IJ!I
(Please type or print and siJtQ at bottom)
ADDRESS
14983 HILLSIDE CIRCLE NW
ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER
(Name) MClJONAT!D CONSTRUCTION
(Phone)
(Address)
APPLICANT
(Name) ALLIED FIRESIDE DBA FIRESIDE HEARTH & HOME
(Phone)
651-633-2561
(Address)
2700 NORTH F AIRVIEW AVENUE
(Address)
ROSEVILLE
(City)
55113
(Zip Code)
.:t.rl.i;-.lMola'lo.l' ~"Ih.+rli"'~...e",.-",
(Contact Person)
BRENDA HUSTON
(Phone)
651-633-2561
APPLICANT SIGNATURE
BRENDA HUSTON
DATE
7/8/03
APPLICANT PLEASE COMPLETE BELOW
xD NEW CONSTRUCTION 0 REPLACEMENT 0 AL TERA TIONS
FURNACE MAKE AND MODEL FUEL
FLUE SIZE RETURN OPENINGS INPUT OUTPUT
TYPE OF SYSTEM
OWarm Air Plants
o Gravity
o Mechanical
OAir Conditioning
DVent. System
HEATING OR POWER PLANT
o Steam
o Hot Water
o Radiation
o Special Devices
o Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
HEAT N GLO 6000TR-OAK
Industrial, Commercial & Multi-Family
FEE SCHEDULE
I % of job cost Residential, Gas Fireplace
$39.50 minimum
$99.50 Residential, Additions & Alterations
$64.50 Residential, AC Only
$39.50
$39.50
$39.50
.';!..<;,.->t'\4ln..):QoIl
Residential, Heating & NC (New Construction)
Residential, Heating Only (New Construction)
Building Official
Date
Building Permit #
$
$ ~ ~~1n
$-~) ~ [0 \.uuU
\ 1 ~ai4H II U ~ I U 0 3
Date
3y
--
PAID WITH
SUIloING PERMIT
i" 'Ii
!', I
\'1 'i1
ii i
~ ) ReceiPfo.
3y I
/'''''.
~
,-
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Your Building Permit When Approved
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
\
FRlJt" : B I t,lDER HEAT I t'~G
PHOt'IE m. :
JI..I.I, 08 2003 10: 35At'1 P2
.,--
s
'-
HEATING/AIR ~~:n~:I~~g,~;~::PLACE PEJ~~ IT; II >>lt~;'I'1
. u[ JUL 0 9 Z003 J
(Please ~~ ?T print and si~ at bottlJm)
ADDRESS
I L.J 983 Hi Jlsid.e Cj,r~Jc t\!w
j, Pil'k File PE
2,~. Cil)l
.1 y.llow AppUean.
ZONING (~_)
LEGAL DESCRlPTION (office use only)
LOT
BLOCK
ADDITION
prD
OWNER
(Name) lJ1c.fJ"llo.lA. U;J1"l5.trvr,t /O/t
(Address)
(Phone) -1 <: ~ - '-L.':?~ - 76 0 I
APPLICANT
(Name) A illde./' He.o.f.i/lJ
(Address) d ~~ H of d IY1 fA n fJ.. ve.... III"
(Addre~s)
(Phone) Ji5 J - l.f.<: 7 -B 7/1 I
-.S.. 51-.. Po vI 55'075
(City) (Zip Code)
(Contact Person) ..J' a f..(.f>../
APPLICANT SIGNATURE
;;:;1 ~, (Phone)
/c.:dr-.(dn A~ DATE
7-8 -03
APPLICANT PLEASE COMPLETE BELOW
~EW CONSTRUCTION 0 REPLACEMENT 0 AL IERA TrONS
FURNACE MAKE AND MODEL .:rvXI~12f, Tretnc;.- FUEL Jr.l.s
FLUE SIZE '?JI RETURN OPENINGS 7 : INPUT I~Jf>O() OUTPUT jo9.00~
TYPE OF SYSTEM HEATING OR POWER PLANT
" DWarm Air Plants 0 Steam
DGravity 0 Hot Water
O! Mechanical 0 Radiation
~Air Conditioning 0 Special Devices
~Vent. System 0 Other Devices
PLEASE NOTE:
Air Conditioner Units
Cannot Encroach into
Required Side Yard
Setbacks
FIREPLACE MAKE AND MODEL
Industrial, Commercial & Multi-Family
FEE SCHEDULE
I % of job cost Residential. Gas Fireplace
$39.50 minimum
$99.50
S64.SQ
$39.50
Residential. Hcating & Ale (New Construction)
Residential, Heating Only (New Construction)
Residential. Additions & Alterations
Residential, AC Only
S39.50
W'iTH S39.50
PAID I
BU'LD'NG PERMIT
fA hI
m(..f}ol1().l~ Lv/l5.f-.
~uildlng Offieil\'
Dar~
BUil:n~ #
S "'-. .50
$ "-
~~~r:;rl
~{ard U '" CJ
lPaUl" uB IIIII~
I~""'~<l'
Estimated Cost $
HEATING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Your Building Permit When Approved
r~-J-\
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C,,",", II Re elpt No.
il
u
"
24 hour notic~ for all inspections (952) 447 DI~~.x19S2)447-424$
From JECHEEXC
PHONE ~h
612 8'326396
Jul.01 2003 6:20AM P01
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!pA,L~'}?"~.i.IIfi!-.llIP'.;,.,'.lI..I". O.,N. (0. moeuaeollly) I
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~~~!~.~. :'la.~~~;:.,~~"': ADDITION 5'7 CV I MfJ__..glJ.....
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;qoD~, ~pn)'~ . i-f.L./i-tr'-'.""' .... ._...___ (Phone)
t~~fJl~~j~~AiiLRE 7 "f;f"hLo /"0'_' _'_'d."",
i;';,~i!~.,'i'" {/
~'-~l~~"ri,;~~'" .
',,';1::< APPLICANT PLEASE COMJ"LI~TE llELOW
. ' Size of water service I incheot;.
'.. Location of Ql1Y couplings f10m btlUl,;tun.::
. Type of sewer pipe. 0 ABC 01)VC
Estimated length of sewer line;2]L feet.
Clean out (if required) located at feet from structure.
CITY 01<' }'IUOR LAKE
SEWER AND WATEH 1'1(~RMJT
"j
; ~~;.:,., ~'\I,~ I PERMIT NO.A'.~ ACI,Q
I 11..1,1 At-J,III..... ~.... fJ
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PIO
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--.- (Phone) 8.I:J 4 ~.17 W
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f (CiIY) '. ,,~, I'. .... ~Code) '\';<!I';-,J;i\. 1
,.... ....-. _.- . ," . ,!.
(Phone)
0__B/.D.QJ111~x+0Y1
(Ciry)
~/;1 "Jr?1J '7L1d., ...',
M.1J 6.l7W':
(ZIp Codt)
~ /1 '7t?? 0 7'1rf".
. DATE r; "'(_~qf~"
kd.
o Cast Iron
FER SCHEI)l)U~
~sldontllll.owor and wat~r line COlUlC<:liulI 3>:I':UO ImJ\lslriul, Com" & Multl.famlly
i.wer cor:'flection onl)' S 17.50 Walcl \:\)IIIH,~(i\)n unly
Estimated Cost $ s..5:..~).__._ Building Permit # .
1 % or Job COSl wlch . $39.S0 minimum
$17,'0
SEWER AND WAT)~R l'ERMlT l'E1'
STATE SURCHAR(ie
TOTAL I'l';H.MlT FEE
:>
$
$
PAID WITH
.50 BUILDING PERMIT
."',
1..lldln,Omdal
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UJhi'id~U"J. L .'i ~occt, No.
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Tit.. Appllc:.Ul)JI Bcc:omn Your QUilt.!;.." Pc,'mil WIlen Apl,rc.",:,1
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lot hftUI' ""lice lor 1l1l1"specficlU' ('JS1).U 'EfN~O. fox (952) 441-4145
. Y ~-.- --... --'"
.... '. ,.-1 ""7-4243
~)
~~
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PER\1.IT
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ADDRESS /Y9.g3 /!/llsid€ Giflv)e N II.
1 Illu, FiI, I' ~."''''I'T NO ~
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ZONING (olliee\llt) \
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LEGAL DESCRIPTION (offict.~se only)
LOTOYBLOCK 0/ ADDITION S+efhoh9 AJJ;fl'o V1
~=Rjjct1no.lJ c'11--S: frlAc1-; on,. 'J,h C. ___ (Phone) C;~J- YJ'J-76o(1
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~ (Address) 7c)93 Je f.(/di JLLc JO, ~ ji,,g () (}r 0 I/e J /1; \> ~ 0/ b
! h\ (Address) I (Cityf (Zip Code)
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I APPLICANT SIONATUllE. -LiJ~,{ ~/ J(/~ _ DATE 7-<2...... ct..Y
r I!.il!.i SCHEDULE
Industrial, Commercial &. Multi-tamil)i 1 % of j<lb cost with a 539,50 minimum Residential, New One & Two-Family $99.50
Residential, Additions & Alterations $39.SO
Estimated Cost fI! -S1J 0 Building Permit # ()... ~ -: (), f"b 9
PLU~BINO PERMIT FEE $ df!ow~ PAID WITH
ST ATE SURCHARGE $ It ~ BU'LD'NG PERMIT
TOTAL PERMIT FEE ~^~----=~..c-~---"~-=.=--
Ii ","\. ~..~~~ 1 '";<\ \-~:.~ r-;, I ,_., '! ' '\ ~
(OfftcelJltOalY1 I U) ('~a~d' i L~ ;' I! I ~,'
" Tha's Appl,' ....""'on o";"omes V our BuUd..ina..Permlt When APproved... I . I "
....u KnN . . . [1 \1 . Barter 2 '1 zore ::
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>>ate " .
14 hOlll' notlu ror all ~tpections (9!2) ~~.!>,"~_~"1.~
Quutity
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APPLICANT PLEASE COMPLETE BELOW
! Type of Fixture I Quantity ! Type of Fixture
Bath Tub with or without shower I I Rough-ins
Dishwasher / ! Water Heater
Floor Drain [ Water Softner
Lavatory (Bathroom Sink) / I Stand Pipe (Washina Machine)
Laundry Tray (lor 2 compartment sink Sewaae '&tector
Shower Stall Backflow Assembly
Sinks ------- -- Backflow Assembly Test
Ba.r Sink Lawn Sprinkler.
Water Closet (Toilet) ---- -- other
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