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Date Reed
ot TRi04,
klivszse.0 CITY OF PRIOR LAKE PLUMBING PERMIT
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PERMIT NO. i _. 7 7 Z......
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3.Yellow Applicant ie
(Please type or print and sign at bottom)
ADDRESS ZONING office use)
3,51 q \nat.°s ' ‘Dcge- N,LA)i
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone) _
(Address)
... ....______.
APPLICANT
(Name) ("U 6rerg. ))2 S (Phone) 7(0 3-.5-31/4r—/go°
(Address) gaol C,e../yriz.vt-t- 14 L-,e- - s'PRINC3 L*l<E PA•rk j ^. 4/v 4.3stesz --scam
(Address) (City) (Zip Code)
(Contact Person) -C-te-oc_ (Phone)
6----/
APPLICANT SIGNATURE . i--.11....0 IIIIII Iilill-.Ai _ DATE i 1I/
NI
APPLICANT PLEASE COMPLETE BELOW
, Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain I 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
" URI e
The Minnesota Statutes§32613 I44 fjoh cost with a$49.50 minimum
STICilinAinRintisurchargehasbeetterxteonrda'et! . Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
"fixed fee"permit is$5.00 $ Building Permit#
.PLUMBING PERMIT FEB $ ctct 1.5 -0
STATE SURCHARGE $ 5.00
TOTAL PERMIT FEE $ S II. SP
(Office Use Only)
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This Application Becomes Your Building Permit When Approved Paid „5—ze crj Re,/,ipt
Date4_ as—, i liw ,
Dulidine Official Date -
4
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 if
4646 Dakota Street&R.,Prior Lake,Minnesota 55372
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