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( CITY OF PRIOR LAKE PLUMBING PERMIT Date Recd
driivinsoo
I.Blue File
2.Gold City RMIT NO. 1S,047
ease I' or „,t and 8' at bottom 3.Yellow Applicant 13 t�
ADDRESS3 / �,J
33 (r wo,) 41, ' 11/
1/1) ZONING(office use)
pzs_15
LEGAL DESCRIPTION(office use only)
LOT '3BLOCK 3 ADDITIOG Nee/4- 47' Z
a._
OWNER (S W,4-6,6 PID = 3 .,
1•
(Name) b. .. . Mt -{s G .. 0-9-(Phone) -I 0-9-G q'g acv
(Address).P.;9D.; 1 1,- IA, cI/ G,1 vJ \--en.\<(,.
A/
APPLICA��'`^O.
(Name) ��V�,�1 • ?'v rn
oC71 �CoS ( 34 0
(Address) 3 C0-7O O (phone
(Address) S S i o`
(Contact Person) (City) (Zip Code)
.►..1Vii
i". ;� (Phone)
APPLICANT SIGNATURE __
DATE . Ct Ao 1.5
APPLICANT PLEASE COMPLETE BELOW
T j,e of Fixture
_� Bath Tub with or without shower uanti T t e of Fixture
alMillIllIll Dishwasher _. Rou:h-ins
_. Floor Drain
MINEIMMINI
IMMIIIIIIIIII Lavato Bathroom Sink Water Softener
—� Laun• Tra 1 or 2 corn.artment sink -_ Stand Pi i e ashin: Machine
�_IIIIIIIIIIII Shower Stall Backflow1111111111111111111 e EAsse
Assembl
Bar Sink —„ Backflow Assembl Test
MINIMMINI_IIIII Water Closet Toilet
1111111111111111 Other
FIndustrial,Commercial&Multi-family 1%of job cost with a$49.50 CHEDULE
Residential,New One&Two-Family $149.50 W,
Residential,Additions&Alterations $49.50
The Minnesota Statutes§326B.148 Building Permit#
"SURCHARGE"has been extended
The minimum surcharge for a ,UMBING PERMIT FEE $ 141 .So
"fixed fee”permit is$5.00 'ATE SURCHARGE $ .50
)TAL PERMIT FEE $____S_4_15_0__
This Application Becomes Your Building Permit When Approved Kt �.2
Rec eipt No. 0:50
Building Official Date B
Date 5
y
Pi( 41111
lir
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372