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` 4 rRZp Date Rec'd
,° �� CITY OF PRIOR LAK.E PLUMBYNG PERMIT
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�lNNB5�� !. Hlue ���� PERMIT NO.
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3. Yelbw Applicant
lease e or zint and si n at bottom
ADDRESS ZONING (otHceuu)
� `J � 2'L 5 �'� �' �Gc-�I � C � /s/L✓
LEGAL DESCRIPTIOI�I (office use onyy) �
LOT BLOCK ADDITION �ID
OWNER
(Name) 1� ��t �� US�� (Phone) 7� 3— 29 Ll '� 3 3�j
(Address) ! 22 -5 ?� Tu CT �� �c,� 5 3" � Z--
APPLICANT (Lca `�,,,y-. �phone) 3
(Na�ne) � 1'�� h � � ,,� rl� � ?�a - 1- �i 1 ' L .S � S'_
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(Address) � �' � 'f �' S1�'-c-c,T ��7�. L'`''�.�'(� pr�i'/�' 1'f7'1'1 � 3 �' �
(Address) (City) (Zip Code)
(Contact Person} � (Phone) �� ` Z� �-' Z ��t�
APPLIC,ANT SIGNATURE ���� DATE I�J ��J 1� j 2 --
APPLICANT PLEA E COMPLETE BELOW
uanti e of Flxture uanti e of T�'lztura
Bath Tub with or without shower Rau h-ins
Dishwasher Water Hsater
• �loor Drain Waf�r Softener
Lavato athroom Sink Stand Pi e ashin Machine
�" Lauitd Tra 1 or 2 com arttnent sintc Sewa e E'ector
Sho�ver Stall Backflow Assembl
S� Backflow Assembl Test
Bar Sink Lativn S rinkler
Water Closet Toilet ���
FEE SCHEDULE
Indusfsial, Commerciat 8c Multi-famiiy 1% of job wat with a$49.50 minimum Residentiat, New �ne & 1'wo-Family 5149.50
Residentisl, Additions & Alterations $49.50
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Bsc�a�a coac � 1�°!y Building Permit #
PLUMBING PERMIT FEE $ �F 4- S
STATESURCHARGE $
TOTAL PERMIT F.EE $ `� `S
(OfIIce U8E Only)
Thfs Appltcatian Becomes Your BniIding Permit When Appraved Paid V-, /� Iteceipt No.� 7 / L(�
7� �'� /
nate ��1�� �� By - �
Bulldine Ofttcial Date
24 hour uottce for all inapecdona (95x) 447-9850, fex (952) 947-424S
4646 Dakota Street S.E„ Prior Lake, Minnesota 55372