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4 PAip Date Rec'd
N� CITY OF PRIOR LAKE PLUMBING PERMIT 13 , ( y
44.,Es�r
,,Gold Cit PERMIT NO.
2.(told City h j • 1
(Please type or print and sign at bottom) 3.Yellow Applicant
6 /�/
ADDRESSZONING((accuse)
`-�3�0 CX1C live p I/s 6
LEGAL DESCRIPTION(office use only)
l
LOT r/ ( BLOCK it ADDITION elleL/� AlJ l PID `c-Y:57-- Q 7i- e
OWNER V\f� G1
i l Phone 1 SL- �5�"' S
I ((��((�� ( )
(Address) 1 3-/0 Cad CA/e (i 1 ? crLac(Pr �
APPLICANT (7 Z , YLCS1=7 Le-7-L 000ame (phone)
'1� ( )Lum
C `(Address) Z2-CO � H W\ J S v I ( I C. S S S
(Address) ' (City) (Zip Code)
(Contact Person) \ * (Phone) A S2:7111400
APPLICANT SIGNATURE E)Y ,I21 . DATE C
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity _ Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 0Water 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
The Minnesota Statutes§326-B.148 j joli cost with a$49.50 minimum Residential,New One&Two-Family $149.50
"SURCHARGE"has been extended ' Residential,Additions&Alterations $49.50
The minimum surcharge for a
"fixed fee"permit is $ Building Permit#
$5.00 (�
PLUMBING PERMIT FEE $ -L -1•S
STATE SURCHARGE $ X )4 5,00
TOTAL PERMIT FEE $ J(-I.sO
(Office Use Only)
This Application Becomes Your Building Permit When Approved '.4 "JL\`<V Receipt No. i I �3 f7 I
BuildineOfficial Date Da v3- (k By Sk -35---'-‘
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.R.,Prior Lake,Minnesota 55372