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Date Recd
CITY OF PRIOR LAKE PLUMBING PERMIT C� /'t ,/ L
I. Blue File PERMIT NO. -A- /-
2.Geld City 1 i /�7
3.Yellow Applicant ! �, 555ddd
(Please type or print and sign at bottom)
ADDRESS ZONING 1 office use)
1730 5 \A.‘\Oet heSs (iycl,e, SE /f 2--
LEGAL DESCRIPTION/�� / ((office use only) �j-/� ��_��77 ���
LOT a�BLt7CK®7RDDITIOrf�� f4'- 646 6 PID
OWNERa 71 p,Li 1 16'17
(Name) �Cry�� L.(3)10V e� (Phone)
(Addresh11770; W 11 CSet s e...-Va e S ?t- oY �(�Ge i 1V �� J ! O'L
(Name)APPLICANTS• r.c.vo `k1`�t� �\Q �M1D\''n (Phone) Y��t l'j '3
40
1.1 6 \ \ .E_0,.0,42,,0 5gta ,
((Address) colDai v �
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(Address) (City) (Zip Code)
(Contact Person) 1i Y c 6-/ziv (Phone) CCE ( 36,5 1 3(A 0
APPLICANT SIGNATUREJC Le DATE t / f3/ t°S
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower ' • . • , ,
Dishwasher 11111.1111111
Floor Drain ,, • - o"ener
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
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
The Minnesota Statutes§326B.148 t $ Building Permit#
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ 49 •50
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee"permit is$5.00 TOTAL PERMIT FEE $ Mlle 0 -'
This Application Becomes Your Building Permit When Approved MIMI
Receipt No. CID
INIMBaildine Official Date M
By _ '
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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