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4 PR/0 Date Rec'd
4e CITY OF PRIOR LAKE PLUMBING PERMIT (C. / 8■ 1,7
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I. Blue City File
2. cola City PERMIT NO. (5 1/ b3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS r C ,p ZONING (office use)
r77 ( / Al/1/17 /J10e f .I
LEGAL DESCRIPTION (office use only) ` �I �
LOT BLOCK ADDITION A O YL PID 2S --'4% -- �d
(Name) OWNER i (Phone) ;/2 32U -3 ! ?0
(Address)
APPLICANT 443 /7� / n
(Name) 4 4 6 - 'tLY (Phone) [�' /.) �,/� .
(Address) : cd . Yd.. C2 udydr "-ve A7_ d ./ lye Wl , A • �1�-,
(Address) / (City) (Zip Code)
. 2
(Contact Person) & ( (Phone) a /)-- d" � 6 f/ PP" 9 Y
APPLICANT SIGNATURE 7,- G /x DATE jd " / 4•
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 ( 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
The Minnesota Statutes § 326B.148 FEE SCHEDULE
SURCHARGE has been extended 1 of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
The minimum surcharge for a Residential, Additions & Alterations $49.50
"fixed fee" permit is $5.00 >t $ Building Permit #
PLUMBING PERMIT FEE $ Vet- d
STATE SURCHARGE $ 5
TOTAL PERMIT FEE $ -g/- c0
(Office Use Only)
. This Application Becomes Your Building :�
W ' 71 X Receipt No. 7 f enAProved
( (- 1 ate / ( By
Buildine Official Date ('�/. c I S
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372