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CITY OF PRIOR LAKE PLUMBING PERMIT '.
1 g 6:;.!/ '''i.,:,,.".
i.Zed rg PERMIT NO. r" zil I
3.Yellow Applicant ��/ ,
(Please type or print and sign at bottom)
ADDRESS ZONING(ofrice,/
�ise)
L--\c a Cor(---es 9r. SE
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION pm a: 337.004":16
OWNERaar V. -e` (Phone) (91(). o�o� ��5��
(Name) Y�
(Address) c\fi--e- _ i
APPLAPPLICANT�, JV 1 '� /L YVI 0%n / a q(Name) gam` IF(Ck1ii, / (Phone) ����
(Address) S r�--0 I K? e/(/ C/ / a l �U iiie t) I f C fel/mil U 35 / )
(Address) (City) CO (Zip Code)
�� (Phone) C /O'`2 9'3 9 C f
(Contact Person) �� �C' �����
APPLICANT SIGNATURE �� DATE
1 �`
—
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantiy Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain ( ater Sof3e
Lavatory(Bathroom Sink) ashing 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 11
The Minnesota Statutes§326B.148 FEE SCHEDULE
riot;cost with a$49.50 minimum Residential,New One&Two-Family
$I49.50
"SURCHARGE"has been extended Residential,Additions&Alterations $49.50
The minimum surcharge for a u
$ - 1 C\. So Building Permit#
"fixed fee"permit is$5.00
.PLUMBING PERMIT FEE $ qL . S o
STATE SURCHARGE $ XMit 5.00
TOTAL PERMIT FEE $ - .0
(Office Use Only) •
This Application Becomes Your Building Permit When Approved Paid 5 W�FEIpt a01(
Date By
Bufldine Official Date , 4
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.R.,Prior Lake,Minnesota 55372