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� pRtp Date Rec'd
,� � CITY OF PRIOR LAKE PLUMBING PERMIT
N �
V Gary Tanner
5410 Deerfield Circle Se
��5��� Prior Lake, MN 55372
. B�u� File pERMIT NO_��� — {
9522261565 . Go�a c�ty
�. Yellow Applicant �
lease type or print and sign at bottom)
ADDRESS ZONING �ot�ce,�>
5�1 D I���' Gt�rcl�e `S�
LEGAL DESCRIl'TION (oflFice use only)
LOT BLOCK ADDITION PID
(NW�NER � WI Tw� � Y� � (Phone)C� � �S(Ji�
(Address) � I `-�� `C/C � � r � v --
APPLICANT
(Name) R�C1l�R1 (ZI�A PI 1 111ARINC� C:n_ (Phone)
(Address) t6 � 2� s�7 -�a33
(Adc�5 GAF:FiELD AVE. SO. (cit (zip code)
(contact Person�'w/ I�Jf I N N EAP4L1 S, MN 55408 �phone) ��
APPLTCANT SIGNATURE DATE I O (� ��
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fixture
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
Industriai, Commercial & Multi-family i% of job cost with a$49.50 minirnum Residentiai, New One & Two-Family $149.50
Residenrial, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 t$ �� Building Permit #
"SURCHARGE" has been extended
unril ]une 30, 2013, PLUMBING PERMIT FEE $ �.�
The minimum surcharge for a STATE SURCHARGE $ ����
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ ��-_5�
This ApplicaHon Becomes Your Building Permit When Approved Paid S � Receip No ��, j�
��
Date I S r � BY
Buildin¢ OfYiciai Date l "
24 hour notice for all inspections (952) 44T-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mianesota 55372
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