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City 2. cola i PERMIT NO. /O . //6,
3. Yellow Applicant
_(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER�j
(Name) (Phone) 7 � '
(Address) 4 GJJJ 4tc, /;')r (� WA/ � . ( ? 7i
APPLICANT a �/ /%' / % , , 4 i (Phone) l ame Gi ��n �h �� ��. • LL 9Z—
(Address) /VC V e J / .5
(Addres) (City) (Zip Code)
(Contact Person) 'IS 7.4'U � (Phone)
7_.
APPLICA NT SI ATURE 4f DATE 12-/z //o
/ APPLICANT PLEASE COMPLETE BELOW
Quantity yype of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher _ j _ 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
The Minnesota Statutes $ 326B.148 Est $ Building Permit #
"SLIRCFIARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 7
July 1, 2010, until June 30, 201i. STATE SURCHARGE $ SO--=
'rhe minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $
is Is beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid � Rec ip o.
Date
Building Official Date /Z• (
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372