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i 1 tot ri cZ y ( PERMIT NO. /*j_e -534 I
3. Yellow Applicant
'lease i , or . tit and sl ; , at bottom 5 3 '7 L.
ADDRESS ZONING (aux me)
LEGAL DESCRIPTION (office use Only)
LOT BLOCK ADDITION PID
OWNER
(Name), 1401 e 3 Fi ee mtei . (Phone) C r 52. 99 -9 Y° L
(Address) 2- , 5 C eir e_ r C./ Pf ( A ge- ,5 5 z-
APPLICANT .
(Name) L ( ci, IA/L.4 T-e,-{ (Phone) "3 2 (.; - 25) -
-
.., ) r ., - e. -
(Address) 32 u , 4- - _)
- i r.e.e i uti 77 44 , _
(Address) (City) (Zip Code)
(Contact Person) -1-3.--i (Phone). 3 L f. , - - 1 - C 1 - 2 - -S 4 , S
i
1 . 7 7 i'
APPLICANT SI9NATURE ez- ',,s Aa'...44,4 ----- - DATE
APPLICANT PLEASE COMPLETE BELOW
• uanti T • e of Fixture IIMIMMI T 1 e of Fixture
Bath Tub with or without shower Rou:h-ins
Dishwasher Water Heater
Floor Drain 111.1111111111111 Water Softener
,,,... Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembl
IIIIIIIIIIII Sinks 1111111111111111111 Backflow Assembl Test
1.11111.111111111 Bar Sink 1.111111111111111
1111111111111111111 Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family I% ofjob cost with a $49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ IOU, Building Permit #
PLUMBING PERMIT FEB $ 4 1 q . 5c
STATE SURCHARGE $ 5,0
TOTAL PERMIT FEE $ 5 5C
(Office Use Only) k ,
This Application Becomes Your Building Permit When Approved Paid , -, / -7
Receipt N o.
/ .,
Bute ate By Official Date ,
24 hour notice for all Inspections (952) 447-9850, fax (952) 447-4245 ,1
4646 Dakota Street S.E., Prior Lake, Minnesota 55372