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Date Recd
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CITY OF PRIOR LAKE PLUMBING PERMIT
N0........./-tkIYY. .Blue Fila _»..__...___..__ ...
.n,.d nlY [ PERMITNO. /i/ / q7 ]
1.Yettow Applkart
(Please type or print and sign at bottom)
ADDRESS ZONING(orrice use)
/ 7S01 )DeerI)`t l c D.r,✓e sE
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
•
OWNER
Name 7001 v- al" /the SCG,r/JJ (Phone) ���- �11� - � �/
(Address) / 7 S ? 1,)cc4_li(r. /6/ ii 4_, -3..E...- iii VA_ ,/k1 M-
APPLICANT
(Name) �d "U Li;itis It>L-7 (O,r D.�_i✓! 9 (Phone) 0J 94----)
(Address) .3�5- 34—d-
04vt_ "(n/ 1i l c...4`nd S o—_J a
(Address) (City) (Zip Code)
(Contact Person) _,.N, 0 n HcAhrC, --
APPLICANT SIGNATURE /e,—
DATE V 7 /Y
APPLICANT PLEASE COMPLETE BELOW
Quantity, . ........._ Type of Fixture Quante Type of Fixture
Bath Tub with or without shower Rough-ins -- ..
Dishwasher Water Beater
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 Matutes - - SCHE
§3268.148 I job cost with a$4FEE250 minimum Residential,New One&Two-Family $149.50
"SURCHARGE"has been extended Residential,Additions&Alterations $49.50
The minimum surcharge for a
Building Permit# ..._........ _,
"fixed fee"permit is$5.00 $ ----
PLUMBING PERMIT FEE $ t/9.}l
STATE SURCHARGE $ XIX 5.00
TOTAL PERMIT FEE $ Sy.,.!---t
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid s J i ' Receipt No. j!� �/j---
Date � ..._ By 4 /, J D_,e'
- Buitdine Official Date
vis*,
�G
24 hour notice for all Inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372