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1:141)cpRI04 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
4rNVESe.
33.Yo aty PERMIT NO/r„
.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
Tinibeit(itteS+ Da_ SE"
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PH)
OWNER
(Name) cfacts (Phone)QS-P-01-7-33,6D
(Address) (03 as 1-iM -C4z.Q S+ L.
APPLICANT e-
(Name) 1bY,j,s App (Phone) Qt5." Lf3S- LIL/;
(Address) c?- O COLVIN (L(Jl. `�[OZt,o, Ot/U t, 61/) L'S- 3 3%
(Address) (` (City) t ' (Zip Code)
(Contact Person) 1..-CW/20- e1 (Phone) 1,L_t- 3S a L `-ipa
APPLICANT SIGNATURE ____Yadd4/44f. DATE 03/0 P1/5
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
FEE SCHEDULE
Industrial,Commercial&Multi-family I%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 Building Permit#
"SURCHARGE"has been extended LUMBING PERMIT FEE $ lI
The minimum surcharge for a TATE SURCHARGE $ 00 .SB'
"fixed fee"permit is $5.00 OTAL PERMIT FEE $ Jr y.SD
This Application Becomes Your Building Permit When Approved Paid / pt No. R
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Building Official Date Date . '"`
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372