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CITY OF PRIOR LAKE PLUMBING PERMIT
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I Blue File PERMIT NO. [�.�/
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Yellow Applicant I I
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(Please type or print and sign at bottom)
ADDRESS L ZONING(office use)
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LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PH)
OWNER 1 AI I M(Crto I e Moor° (Phone) q6.2"114 7- g5-18
(Address) ,
O&I"' 12.46 C'i J� )r o r L4ke,
APPLICANT Ap;,: .-: - ., .,;1: -s.,
(Name) 12350 Chest:--;.,:i
Lis (Phone)
(Address) Shakopee, MN 55379
(Address) 952 415 4803
(City) (Zip Code)
R )C
(Contact Person) Z-GUA 1 C KA I (Phone)
APPLICANT SIGNATURE f�4 Y DATE 5-Phi
A PLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher i 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
FEE SCHEDULE
"ob cost with a$49.50 minimum Residential,New One&Two-Family $149.50
The Minnesota Statutes§326B.148 Residential,Additions&Alterations $49.50
"SURCHARGE"has been extended
The minimum surcharge for a Building Permit#
"fixed fee"permit is$5.00 UMBING PERMIT FEE $
FATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 51140
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid s44_51 Receipt No. pL
Date /�j/�J� By /4
Building Official Date 7` `f` �,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372