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pitiO4 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 5--r /3. /S
' sdit.
Gold
File PERMIT NO.
2.Gold City ! �
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
3 g57 4,s,he�% ��s{ /?S f '/o , 1- kc
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT
(Name) /4e II Z' /14 lo..i (Phone) G/2 ' 7 Zo- i'j 7
(Address) 3 g5i A A 5/hv7 Al it 4d V,p r/0, L•c ire A4//✓ 653 7Z
(Address) (City) (Zip Code)
(Contact Person) Geoa:.,).E 6.'„f (Phone) 452 - `1Y7- /
APPLICANT SIGNATURE L G1s--- — DATE .57/3—/5
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 $ Building Permit# The Minnesota Statutes 13 2615.1411
"SURCHARGE”has been extended
PLUMBING PERMIT FEE $ 'The minimum surcharge for a
STATE SURCHARGE $ S.--4/22 "fixed fee"permit is'$5.00
TOTAL PERMIT FEE $ 5 f� )
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 6i j s� Receipt No. /Z` Loy
�/
Building Official Date Date'-- /3 ` By
24 hour notice for all inspections(952)447-9850,fax(952)447-4.245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372