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Date Rec'd
04rxroR CITY OF PRIOR LAKE PLUMBING PERMIT /a - F. /3N
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I.Blue File2.Gold City ��PERMIT NO. 9
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-•�y�1yS�.i� 3 Yellow Applicant
ZONING(office use)
lease 4. or ,rint and si 1, at bottom . /
ADDRES99E S
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LEGAL DESCRIPTION(office use only) - PID �j—, (� � S
ADDITION . 1/,' -- AP t
LOT�BLOCK - 1 )A I is
(Phone) L-; -/`�(<'
OWNER J it S
(Name) .`.J �
Z) p. iAJ-) e ._
(Address) �r
APPLICANT i �I l CgI (P 9 —s — ♦ I i
(Name) IS ,C W, hone) I
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/ 27 4 A -1 �j (Zip Code)
(Address) ((,� (City) �' �"��J � ♦���
(Address) _
/l'V/' � S��'�j��" (Phone) `/ -
(Contact Person) •
*J �jii DATE
-tet 1� '
APPLICANT SIGNATURE - '' " �
APPLICANT PLEASE COMPLETE BELOW T�,e of Fixture
Quanti
T i e of Fixture 1111111111111111111 _— Routh-ins
Bath Tub with or without shower
_— ,CW-# Pi i 111111111111111
IIIIIIINIIIN1111111111111111 Softener
—� La
Floor Drain Stand Poft Washin: Machine
Bathroom Sink Sewa:e E ector
1111.111111
Laund nd Tra 1 or 2 coin•artment sink — . Backflow Assembl
111011011111 Shower Stall Backflow Assembl Test
11111111111111 Bar Sink111111111110 ._ Other
Water Closet Toilet
FEE SCHEDULE
Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
$ Building Permit#
The Minnesota Statutes§326B.14850
"SURCHARGE"has been extended
PERMIT FEE $ e
unil June 30, STATE SURCHARGE $
The minimum surcharge
chh argerge for a TOTAL PERMIT FEE $
"fixed fee"permit is$5.00 i
�`�' Receipt No. fi A lication Becomes Y l ,r Building Permit Wh; Approved kir
1:Y.to .���
ThisPP � ... c - By ,
- Date
Buildine Official
gr 24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372