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11 '1a.On
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT~ 8. IS. Of,
REQUEST FOR FINAL ~
INSPECTION SENT TO
HOMEOWNER 10-06
(JotJ::::-11'15/F-fhf/
File
City
Applicant
I PERMIT NO.O~. 0739' I
/
ZONING (office
use)
at bottom)
/VIE
LEGAL DESCRIPTION (office use only)
LOT
BLOCK
ADDITION
PID
OWNER
(N ame)
'E-r/c
/fcffle~
(Phone) q~ -~ /7-5693
(Address)
5 &f fY\ --(
APPLICANT r
(Name) IY\ C ~l.-r ,re_ +-5' OnS
(Address) (; 0 5 I ~.j-h. ~.e S-
(Address)
(City)
<:[5). - ?3/-9ro 7p
5531'3
(Zip Code)
)
..tI
(Phone)
ffof jc,'", <;'
-
-.
--
(Contact Person)
m e l('S>~
(Phone)
~~~
DATE
~ - g- OG;
()
~
(\
~
APPLICANT SIGNATURE
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 Softner
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink -- ~~wage E~tor
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 $39.50 minimum Residential, New One & Two-Family $99.50
Residential, Additions & Alterations $39.50
Estimated Cost $
Building Permit #
PLUMBING PERMIT FEE
STATE SURCHARGE
TOTAL PERMIT FEE
$
$ ___.50
$ ~OG 00-
ffiee Use Only)
This Application Becomes Your Building Permit When Approved
BuUdinl!: Official
Date
Paid 1-0. ()()
Date 1,,~,d(P
Receipt NO'5 Z 22-/)
By