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Date Recd
A 4 Ry e CITY OF PRIOR LAKE PLUMBING P ERMIT
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ar $o 2. I. Blu Gole d F y ► 2 i I PERMIT NO. (2 (O
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3. Yellow Applicant
(Please type or print and sign at bottom)
ZONING (office use)
ADDRESS
I -.R S - TA K ifQ I-A- Cooki7r MVO
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER TI.V W"t Ll I ST (Phone)
(Name) // __ /?
(Address) ) t0 . � 5 i�. i n) led L C 9 (../ /J 1A .,,�
APPLICANT r7 �,� � ���C. � (Phone)
(Name) (vUY j
1-2d-C1 I iti T724 V -e_ lest_ z- 53 ? Z_
(Address)
(Address) (City) (Zip Code) (Contact Person) ®ti L%. � r ,L '24 Z _
�� - (Phone) 1-0
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APPLICANT SIGNAT DATE URE Ili"
APPLICANT PLEASE COMPLETE BELOW Type of Fixture
Quantity Type of Fixture Quantity yP
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
l Shower Stall Backflow Assembly
Backflow Assembly Test
Sinks
Bar Sink / Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi family 1% of job cost with a $49.50 minimum Residential, Addit s & Alte rations $49,50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ .50
STATE SURCHARGE $
TOTAL PERMIT FEE $ q. 7
( Orrice Use Only) 1 Receipt No. �-� 5 * This App i io Becomes Your Building Permit When Approved Paid -��
----- - - ---i Date o By
Bui
Date (, ( Z I Z CO t)'S
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372