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t o4 pRtp� Date Rec'd
,� CITY OF PRIOR LAKE PLUMBING PERMIT
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i. Biue Fik
2. ��d �� PERMIT NO. Io2 - I3 � 7
3. Ytliow �
lease or t and s' at bottom
ADDRESS ZONING (oflece use)
c� v 6 w �� CV (� �J�/ .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER "'1`� �'� (� ��(�
(Name) F (Phone) ��,1� � f �� �
(Address)
APPLICANT (��,R1p�A� �IUF�k�I�E,�
(Name) (Phone)
(Acldress) fi51-3fi5-134�
(Address) 3670 Dodd RoSd (City) (Zip Code)
(Contact Person) Eagan, `MN�f 51 �^� - - �phone)
APPLICANT SIGNATURE DATE � V " �� ��
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fixture
Bath Tub with or without shower Rou -
Dishwasher ater Heater
Floor Drain Water o ner
Lavato Bathroom Sink Stand Pi e ashin Machine
Laun Tra 1 or 2 corn artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
Industriai, Commerciat 8c Multi-family 1% of job cost with a$49.50 minimum Residential, New One & Two-Family $149.50
Residenrial, Additions & Alterations $49.50
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Estimated Cost $ ���-- Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Oaly)
This Application Becomes Your Building Permit Vt'hen Approved Paid �� /. L--�1 Receipt No.
7'Jv
Date�O j / By
Buitdin¢ Off[cial Date /
24 hour not3ce for all inspections (952) 447-9850, fag (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 �, p�
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