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Date Rec'd
( g O ; CITY OF PRIOR LAKE PLUMBING PERMIT
M/4-/) )3. 51
1. Glue Ci PERMIT NO. /� /,
2. Yel A 13 — /�Y�
(Please type or print and 3. Yellow Applicant
sign at bottom)
ADDRESS ZONING (office use)
3(e7 - r6c D-, , Pa 5 _4b
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION.//-t: o 1 4 /I PID 2,- 1M - 0/ -,4
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((Name) R (Phone) & / Z 7 0 2
(Address)
APPLICANT f
(Name) / thJ tiL 'W`�?i5 t (Phone) ' / Z 'en' ff- Y f
(Address) . VZ &u h._ec / i(/ ) III✓ /y1N �/ V
(A t (City) A/ / (Zip Code)
,{�
(Contact Person) f� b 2 \ Mtge (Phone) a /2) 60 4 7 9,I
APPLICANT SIGNATURE ala------ . DATE I (1' 7 / O
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
The Minnesota Statutes §326B.148 FE SCHEDULE
>f job cost with a $4 9.50 minimum Residential, New One & Two - Family $149.50
"SURCHARGE" has been extended Residential, Additions & Alterations $49.50
The minimum surcharge for a
"fixed fee" permit is $5.00 $ Building Permit #
PLUMBING PERMIT FEE $ 1 9- fJ
STATE SURCHARGE $ c 4)
TOTAL PERMIT FEE $ may,
(Office Use Only) �, v
This Application Becomes Your ildin Permit Wh A oved
g Pp �� n / CO Receipt No.
/ 7 j
I u (f� Date ( ,J ''� g b
Baud t Date 1 0 t 1 « y A
O coat S
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
.