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4 PRIo Date Recd
4.1 CITY OF PRIOR LAKE PLUMBING PERMIT - .
U
d ow n ed . -- -
x , R e t, PERMIT NO./ , � r
3, Yaw AppBaat
(Please type or point and sip at bottom)
ADDRESS ZONING (oke use)
/9 0 9 S(A r /AhL iJE P--■
LEGAL DESCRIPTION (office use only) •
LOT BLOCK ADDITION PID
( OWNER. r
, - j`c. for th (Phone) 61) - , Py9- a qi�
(Address) L A 09 SiA ,-ryLA i-le,_ 1 f2, OrL Likie, " Al J - . 7 7a
APPLICANT --�
(Name) Tr l Cv A ' Ty (�G�7Cx_ C 1i h m 4ic, (phone) 3`.2 d — LP t— 9 SD
(Address)
(Address) L (City) (Zip Code)
(Contact Person) n ) (Phone) g a 0 — TX 7-- .2 ?SD
APPLICANT SIGNATURE DATE 1.1 ) 3- -- t-?
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 w Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
FEE The Minnesota Statutes S
32611-'4 ., m f costwith $49.50 SCHEDU Residential, New One& Two - Family $149.50
"SURCHARGE" has been extended ' . Residential, Additions & Alterations 549.50
The minimum surcharge for a .
"Rxed fee" permit is s,Q � $ Building Permit # ,
. PLUMBING PERMIT FEB $ ` g"'
STATE SURCHARGE $ ixe 5.00
TOTAL PERMIT FEE $ ..1 4V
(Oftice Use Only) • •
This Application Becomes Your Building Permit When Approved Paid ,..5-g s151 i t No. 705-.2 z__ 8uitainaOttictai Date 178te ,� •
i
24 hour notice for ail nspectlena Q om ) 447 fax (952)447.4245
4646 Dakota Street S.E., Prior L�rke, Minne ota..S5i72
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