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. Gol ei1e PERMIT NO ? - 4
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3. Yellow Applicant
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ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER / /
(Name) `� - ' (Phone) 4 ( -....?4 3 9I
(Address)
ANW04 caet. JLi6t .. 612 - .,G
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ddress - Z 2- UC � �iC,- y
(Address) ' (City) (Zip Code)
Contact Perso ah „ At._ (Phone) 6 / 2 la 0 Ge f
- ° ICANT SIGNA r ,___ allii. DATE 0" - 43
ille
APPLICANT PLEASE COMPLETE BELO -
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family I% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $P''' Building Permit #
PLUMBING PERMIT FEE $ 2/q"
STATE SURCHARGE $
TOTAL PERMIT FEE $ S
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid S CL) R - . No.
Date / ) B
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 111
4646 Dakota Street S.E., Prior Lake, Minnesota 55372