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04 PRtO, Date Rec'd
t CITY OF PRIOR LAKE PLUMBING PERMIT
/0. /e /_3 v
de soy° 444m is. /d a
1. Blue File PERMIT NO.
2. Yell City /3_
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
g 03 f - • - 7 _ 7),)S_6
LEGAL DESCRIPTION (office use only)
LOT /3 BLOCK / ADDITION (' 1 � K/ 2-NV HD - yg/?— D73.- d
Z 3
(Name)
Die., 4�� � Ii�O�f hone '(� c,�� �'9'86
LJ �Cj (I' ) / /
(Address)
APPLICANT �a / 54 /,, L'
(Name) �p 1/' (/! G.�°,S (Phone) �//� �
is �XJ ' / S ---
(Address) 5 Q I.) c /4-14.4_. /UQ • N& -5 Aey, Mmi . "r
(Address) L (City) (Zip Code)
'
(Contact Person) _`, 5 4--- A ? Ze..... (Phone) kZ �. e ' 179.5
APPLICANT SIGNATURE 4 DATE lb /, .:://...._? �
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 I 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 O k) ( n j, t4k A/ k
The Minnesota Statutes § 326B.148 FEE SCHEDULE
"SURCHARGE" has been extended )f 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 $ Building Permit #
PLUMBING PERMIT FEE $ (I J - J
STATE SURCHARGE $ 5 00 .
TOTAL PERMIT FEE $ (511.,57)
(Office Use Only)
This Application Becomes Y ■ ur Building Permit en A proved !VVii: J tt yS V Receipt No.
A--- 0 ( ' (3 s a B 7 �l c it.f3
Bu dins � 41, Date
. [ �t By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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