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wtelle711110 —`"...41t911111.1.11
04 11 R104 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
4 sdo I.Blue F
3.YelAile p PERMIT NO.
3.Yellow
Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING,:office use)
/6, eaccip dij F, alaf.
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PB)
OWNER
(Name)
/��"` n 06W/"1�l � '�
� ) (Phone)
(Address)
APPLICANT /
(Name) / p�,
(Name) �ll �l'CQ AUC (Phone) 6,1 (rll�i—t'f Y fr
(Address) Z aZ (X (A 41° /I!- de4/ ',-C S eXi
// (Address) (City) (Zip Code)
£h(Contact Person) .14 (Phone) ( /�^�t 0' f / gJ
APPLICANT SIGNATURE e/ t,&. DATE
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 / 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 1%of job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
Estimated Cost $ vq- Building Permit# t..will ,,,,Ld JLcIt
'SURCHARGE"has been cxtende(1
PLUMBING PERMIT FEE $ k hr, rninimum surcharge rct a
STATE SURCHARGE $ g
TOTAL PERMIT FEE $ wed lee" per reit is:1,),(
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid /, - s/ Receipt No. ,// �
Buildine Official Date Date ` �6z) By ,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372