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d i rRro� CI OF PRIOR LAKE Date Rec'd
N AKE PLUMBING PERMIT
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I. Blue File
2. Gold City I PERMIT NO. Z I
(Please type or print and sign at bottom) 3. Yellow Applicant
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ADDRESS
3 J� / ZONING (office use)
1lff// (0 eUrafill c7
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION
PID
OWNER / /
(Name) (Phone) 62-36 & 3 /
(Address)
APPLICANT
(Name) �
jkaiii, (Phone) 4 / ) (Pb t��
(Address) v. Z T Z 6 4. . ��7
(Address)
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cre (City) (Zip Code)
(Contact Person) r, ,/r /�
/ (Phone) 4/..2 c et— ��
APPLICANT SIGNATURE ./ ' - ,
DATE 1 7 - ;...0'�
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture uanti
Bath Tub with or without shower Q Type of Fixture
Dishwasher Rough -ins
Floor Drain Water Heater
Lavatory (Bathroom Sink) Water Softener
Laundry Tray (1 or 2 compartment sink Stand Pipe (Washing Machine)
Shower Stall Sewage Ejector
Sinks Backflow Assembly
Bar Sink Backflow Assembly Test
_ Water Closet (Toilet) Lawn Sprinkler
Other
FEE Industrial, Commercial & Multi - family 1% of job cost with $49.50 minimum m
Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
(Office Use only) TOTAL PERMIT FEE $ c*�
This Application Becomes Your Building Permit When Approved Paid
�-4,J1 ---6 Receipt No i i f .Z
Building Official Date ` 7`,30!/ By
Date ��V ...er...
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372