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PRIp� Date Reed
CITY OF PRIOR LAKE PLUMBING PERMIT '. J5-' Js 1
a' xsoo
1.Blue r'l` PERMIT NO./5 d'�?t
z Gold city
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(o(ofce use)
.. • , - crest Dr 6t . �CUJ(J
LEGAL DESCRIPTION(officexe only) �- •
LOT BLOCK ADDITION IC, C/3 f Mit cieas. t.p�C vi R5-- i1/0-0, -,0�
OWNER. A
(Name) lei q . ACM t 7Liri/44-te)-✓t #11a...1171— (Phone) _
(Address) 33 9‘ 61-r5.J S _sl J'tiGc)
APPLICANT
(Name) IgA-id- .Sort.= Pi v.v..I,r'Al (Phone) x,/76 3 ' V ZS: 02996*
(Address) 3'//O �r/wr et- LA) N p ictodlfi "ti 3-3Y54/ _
(Address) ( ity) (Zip Code)
(Contact Person) ___/_.--12________/44 _ (Phone) 7/3 ,`i 7S e -9 6
APPLICANT SIGNATURE e4— $424, mo
DATE 7'47 —/✓-- _
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
FEE The Minnesota Statutes§32611.1'¢8 oli cost with a$49.50 minimum�E Residential,New One&Two-1~amily $149.50
nit-num Surcharge for a
"SURCHARGE"has been extended . Ii
Residential,Additions Sc Alterations $49.50
The nll •
"fixed fee"permit is$5,00 $ Building Permit#
.PLUMBING PERMIT FEE $ Lig.co
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $ SY•L5 0
(Office Use Only)
•
This Application Becomes Your Building Permit When Approved - 50 Receipt No. / a f)f
✓ 1` v I
,0 ate By
Bulldine Official Date •(15. 1 S
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372