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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT `0 . y,!g-
v
4tlse 1. Blue File
ooid City PERMIT NO. /¢ 71
—0
3.Yellow Applicant •
(Please type or print and sign at bottom)
ADDRESS ZONING i office use)
3 15 S 1 Pc '( Co'I P o 11- (NAO.
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER SjSO r'a 1'� / ;64
(Name) ��. . '62 7�� (Phone) V
(Address) gr S >1A D Ce JL Po A- IJ. co
APPLICANT
(Name) + - a� Z (Phone) 5 'a a 1 /o (•'t
(Address) ( SG s ftite,
UJ Co / PO "('tor L SS 37 2
(Address) (City) (Zip Code)
(Contact Person) I442 tL ,QST (Phone) of Sa–X�/ —6 4
APPLICANT SIGNATURE J r V DATE l0 9
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>br 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 $ Building Permit# The Minnesota Statutes§326B.1413
�'�.§-r) "SURCHARGE"has been extended
PLUMBING PERMIT FEE $
$ 1 The minimum surcharge for a
STATE SURCHARGE
TOTAL PERMIT FEE $ sr "fixed fee permit is$5.00
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid5 5-0 Receipt No.72 IA.
4
Date/Q q fel.. By a
Buildine Official Date /
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372