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CITY OF PRIOR LAKE PLUMBING PERMIT
opt` 1.slue Fitth PERMIT NO./
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3.Yellow Applicant I �` ��C�
(Please type or print and sign at bottom)
ADDRESS ZONING(olilce use)
53 Trez-1 L-n:_ 5E, �r�c;r MN1
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(Name) ti h h F4,S y-fA (Phone)
(Address) 5 'h c C- r» i . Fr1-6r c� 1 NI 56 3 7Z
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APPLICANT -7-
(Name) M <.O 4/ -ce- 1 yt.tYraz't ` (Phone) `15 2 -1 S 3 -ylo`7'
(Address) 17L4 g�{ 600 d I ated, 13 L /1-e_. � C So
44.
(Address) (City) (Zip Code)
(Contact Person) (Phone) S 2 - 'I S 3 3
APPLICANT SIGNATURE d , .L . 'a .A- _ = DATE '7/o2a /v`
_
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 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
The Minnesota Statutes§326B.148 ii FEE SCHEDULE
o!i cost with a$49.50 minimum Residential,New One&Two-Family $149.50
"SURCHARGE"has been extended Residential,Additions&Alterations $49.50
The minimum surcharge for a
$
"fixed fee"permit is$5.00 Building Permit#
PLUMBING PERMIT FEE $ 4.9. `6-0
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $ <3 (5—
(Office Use Only)
This Application Becomes Your Building Permit When ApprovedPaid R aipt No. 151
Date
Building Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372