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04 PRIp$ Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
z lotedplPERMIT NO.
3.Yellow Applicant
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(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) i G� NlUv,5 (Phone)G Sd S 1 S
(Address) l to lr'l Or) e P. I'd e
APPLICANT
(Name) P V n,/‘'t6 e - `1-3 4 A (Phone) S d 3 S- -7 7 ^7—7
(Address) -7 S' L )GLS k i n ci Iv-, A v c< e P Ye( t c )„GAJ S 3 ("4
(Address) (City) (Zip Code)
(Contact Person) if a.
(Phone)
APPLICANT SIGNATURE tlL DATE a � -7 I
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 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
FE The Minnesota Stntutes§3261.148 poi;cost with$49.50 minimum Residential,New One&rwo-Family $149.50
"SURCHARGE"has been extended Residential,Additions&Alterations $49.50
• The lninlmunl surcharge for a
"fixed fee"permit is$5.00 $ Building Permit#
-PLUMBING PERMIT FEE $ u•cI
STATE SURCHARGE $ XXX 5,00
TOTAL PERMIT FEE $ S-(4 .S-42)
(Office Use Only) •
This Application Becomes Your Building Permit When Approved Paid 54-V2, Recei t No. (0
'�(JJl
Date 3, 045-`t.'r By
Buntline Official Date 7 -
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372