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CITY OF PRIOR LAKE PLUMBING PERMIT Date Recd
4
isi
44NEsoo
I Blue File
lease j, or , '"t and si_." at bottom 2 Gold City PERMIT NO _
ADDRESS 3. Yellow Applicant /� %{
A1C .J
/ 0 a , it/ A ' ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
OWNER„---- PID
(Name) 0 i
(Address) 4 V (Phone) — ..
APPLICANT
(Name)
(Phone)(Address) fan
12850 Chestnut ewd.
(Ad,'. , :' .� ,
`- ' . (City)
(Contact Person) 4 / ' - ; OF OP (Zip Code)
APPLICANT SIGNATURE 1 II
, I NW (Phone)
— DATE II
APPLICANT PLEASE COMPLETE BELOW
T 1 e of Fixture
_- MIN Tub with or without shower M �'111111111
T/i a of Fixture
Dishwasher IIIIIIIIIIIIIIII
—_ Rou_h-ins
...._____11111111111111 Floor Drain
1111.111111111 Lavato Bathroom Sink Water Softener
11111111 ............._1111111111111.1_ Laund Ira 1 or 2 com•artment sink Stand Pi.e Washin: Machine
__ Shower Stall Sewa:e E'ector
1111111111111111
_� Backflow Assembl
89!!!!
ar Sin _■■ Backflow Assembl Test
Water Closet Toilet
minimo Other
FIndustrial,Commercial&Multi-family I%of job cost with$Eg E SCHmEDULE
m Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The Minnesota Statutes§3268.148 't $ Building Permit#
"'SURCHARGE" has been extended
The minimum surcharge for a PLUMBING PERMIT FEE $ ,
STATE SURCHARGE $
"'fixedfrE"' permit is$5.00 TOTAL PERMIT FEE $
,
This Application Becomes Your Building Permit When Approved Paid
j--/ sv Receipt No. /L
Building OfficialDat---;-------- Dat r/ / B %
y ,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 /
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372