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� pRip Date Rec'd
,° �� CITY OF PRIOR LAKE PLUMBING PERMIT
� ,� John Ansell
v �'' S952 Flandrau Circle Southeast
�jNNESO`�P Prior Lake, MN 55372
. Blue File
9524409127 . coia c;i PERMIT NO. �� �� C� �
��, yellow Applicant
lease e or rint and si at bottom
ADDRESS ZONING (ofece ase)
5���- ��a�d rr�„u �r �e -�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
� ( ��I�,�' V� / 1 I ���1/S1 (Phone) ��5��T7V ^ 9���
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(Address) � G
APPLICANT
(Name) A1�1G?RI n�Dl 1 t11AR1Atf� C'`.C�_ (Phone)
(Aaaress) (612) 827-4033
290��FIELD AVE. SO. (ciri) (zip code)
(Contact Person) MINNEAPOLIS, MN 55408 ���Yy� �phone)
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APPLICANT SIGNAT DATE
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Figture Quanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEESCHEDULE
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
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The Minnesota Statutes § 326B.148 ���st $ . Building Permit #
"SURCHARGE" has been extended pLUMBING PERMIT FEE $ T'/ .�
until June 30, 2013,
The minimum surcharge for a STATE SURCHARGE $ 5
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ � S�;
This Application Becomes Your Building Permit When Approved Paid Y��71 Receipt No. ��
.7 ..� v
Date /3 //� By �,�
Buildin¢ Ofticial Date
24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372