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? IL/ _ 2959 II 5-i .
0to, Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT •.'nvxEsds
I.glue Fite PERMIT NO.
3.YlApp p/-,54
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS Tr-0);
ZONING(office use)
6695 poi46
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER Bruce. ba
.SO �
(Name) (Phone) JZ— 2@3- I (
(Address) 3U' L � r C k \7®\�-\-- C\-- IN U\-)
APPLICANT ( a: Rlain (Phone) CIS 2 l�-7" /000
(Name) r� ` '�/ I
(Address) 2,20Q (A)\/ t S B w- (lS 1� i l 62 SS-331
` (Address) / (City) 9s2---1
(Zip Code)
(Contact Person) (Phone) 697 /00 0
APPLICANT SIGNATURE iiuU 1-3Q./624_, DATE (-001 I LI
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher a 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
The Minnesota Statutes§32613.148 {job cost with a$49.50 minimum Residential,New One&Tw0-Family $149.50
°SURCHARGE"has been extendeda Residential,Additions&Alterations $49.50
The minintutn surchaige for
"fixed fee"permit is$5.00 $ Building Residential,
#
PLUMBING PERMIT FEE $ l t So
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $ 5L/-SCS
(Office Use Only)
r
This Application Becomes Your Building Permit When Approved Paid !--„ 7) Receipt No. ,/223
Buudine Official Date Dates / By / /„
/7 'f
/i L.-__-
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 +�
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
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