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4,0% CITY OF PRIOR LAKE PLUMBING PERMIT •. f`g ii/
''$''" r''` PERMIT NO. >//i 7
3.YsH City / / /
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(ofce use)
I LI 8 ii , 9 /14„ ,--/,, ,c1 NRis
�
LEGAL DESCRIPTIO (office use only)
LOT ' PinI IPID 025 053- ;40 0
OWNER
(Name) J� a r^ n /U t 4.----' (Phone) cifd ' ?di - I (o P'
(Address) /(/ (.0q a , i•1,u . Ai£
c�
APPLICAN
(Name) rah 'A) /---/r A 717''t 4 C (Phone) 9sd 0 35- ^7 7 7 7 —
(Address) 7,1V fs IL i l 4 i I” Ave (' t-c/c i ,if-11 '�'a 4/7/•-/ ,r .7)ci(---/
(Addr ..+ / (City) (Zip Code)
(Contact Person) ..____
'A 4 (Phone) _
APPLICANT SIGNATURE _ DATE
q /3i / Li
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 Water Heater
Floor Drain Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
•
Laundry Tray(I or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet(Toilet) Other
FEE SCHEDULE
T°he Minnesota Statutes§32{$,1'48 I joli cost with a$49.50 minimum Residential,New One&Two-Family $149.50
SURCHgfl�B"has been extended Residential,Additions&Alterations �3
• The mImnlu►n surcharge for a ��
"fixed fee"permit is$5.00 U ,� Building Permit#
-PLUMBING PERMIT FEE $ LI 9 -
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $ y . I'M
(Office Use Only) -
This Application Becomes Your Building Permit When Approved `7 id ( TIM Receipt No. , (i1 ..
Date -, By
y
BulldlneOfficial Date G, - ��
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 /
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372