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4001 CITY OF PRIOR LAKE PLUMBING PERMIT -. 3 7
I.= Fct PERMIT NO. �)qi
3.Yellow Applicant /'J.. 1.(i
(Please type or print and sign at bottom)
ADDRESS ZONING(office me)
1M4a0\ SVCreAiJ. v))
LEGAL DESCRIPTION(office use only)
LOT 1(BLOCK If ADDITIONJ-44✓.s 5- ,/e44)111 -4-1 it PID 60/ 0.2d-0
O(Name)
RUD‘(\!(\ SeA\\ (Phone)% "aa k0 )
(Address) V- \ Share. Ql-ex - ray, J
APPLIC
(Name) _ ko,jf\I\P t ALX) L\C (Phone) ( off -15to-aass-
(Address) 11A,O'N ari Av , l_e_Caltcy nD(-F-5^I
(Address) (City) (Zip Code)
(Contact Person)'a-C e-/I (Phone) (SG I —351 R-TE)
APPLICANT SIGNATURE DATE 8 a _1
1-1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 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
The Minnesota Statutes§326B.148 pot;cost with a$49.50 minimum Residential,New One&Two-Family $149.50
"SURCHARGE"has been extended Residential,Additions e&Alterations $49.50
• The minimtun surcharge for . 'S q �
"fixed fee"permit is$5.00 Building Permit#
•PLUMBING PERMIT FEE $
STATE SURCHARGE $ X) )4 5.00
TOTAL PERMIT FEE $ 51-1.57
(Office Use Only)
•
This Application Becomes Your Building Permit When Approved 1 9t t _s o Receipt No. eu 1 1# q
ate1� 'By
Buiidin¢Officialfclal Date � .�� 1 •� `l � E
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
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