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CITY OF PRIOR LAKE PLUMBING PERMIT `0 a , .
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(Phase type or print and siga at potion])
ADDRESS ZONING (office
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LEGAL DEScRR PTION Mar use only)
LOT BLOCK ADDI'T'ION Pin
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OWNER
(Name) Y P S 4 or�f.S {Phone) 7 to3 - e S3
(Address)
APPLICANT
(Name) Ott C_tr"t iktel ntf LLC (Phone) 1p1 i- 7- x°
(Address) AI o4 C //D W AI plfn raj. S 7 M Al 55 9,
(Address) (City) (Zip Code)
(Contact Peron) 1 L, r` ,c.�2,� (Phone) Cott - B/ 7 -6 -7 3r
APPLICANT SIGNATURE C ,> / �'z ." -- -- DATE ?- Z 7 - Z p t
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
I Dishwasher j Water Heater
Floor Drain Water Softener
a Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
1 Sinks ac-HD. 1 5 90 1 Backflow Assembly Test
Bar Sink Lawn Sprinkler
a Water Closet (Toilet) Other
FEE SetiF:nL1LE
industrial, Commercial & Multi - family l% of job cost with a S49.50 minimum Residential, New One & Two - Family Sl49a0
Residential, Additions & Alterations $49.50
Estimated Cost S _L 0 0 0 Building Permit # 7 /2-//
PLUMBING PERM[F FEE $ .5/37) _ # ,ke2ea tor
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