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4 p R/04, Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
diIHNEsoo I. Blue File PERMIT NO .
2. Gold City /3 _ /2 7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 3 W; Ideircss Tr\ .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) *MI t I , I Z- (Phone) Uli--4'L1 1 — 3f I
(Address) 1 V' 1 berness I r • i Prior LAU, i Mn J ,
APPLIC • T g Rc Oir
(Name) • 41 xt � . , .. _ ■ A , i / . I& 1 (Phone) LQ1 ^ a - • .0 1�
(Address) \1 k� 2D 5 7V inn �1I:S 1 1\ - 55
(Address) (Ci ) (Zip Code)
(Contact Person) J oSh 1\I in Sint +h (Phone) t P13- n 'i a
APPLICANT SIGNATURE /a 14/11 44 .4... , DATE 3 --- - - L2
/ APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain 1 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
HEDULE
Industrial, Commercial & Multi- family 1% of job cost wit 4 , inimum Residential, New One & Two - Family $ •' -'
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148 `` tt
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ ` r
until June 30, 2013, STATE SURCHARGE $ 1 0'=
The minimum surcharge for a TOTAL PERMIT FEE $ s . 6C)
"fixed fee" permit is $5.00
t. ma tipplmittutu nccvuic3 1 uui /Ju..ding Permit When Approved Paid 4 - 4 ) sp Receipt Nob d
p�� J0
Date 4_03 tt By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372