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O* PRIp�
'� CITY OF PRIOR LAKE PLUMBING PERMIT Date Recd
I. Blue File
.lease Z.Gold City 1 � ', ,
/ 02, t and 8'y. at bottom3. Yellow Applicant !'i
ADDRESSApr
IS719 pa ,o_ ZONING(office use)
ar
LEGAL DESCRIPTION(office use only)
LOT 1 BLOCK ADDITION ii /fJ7 40,0& Z"-'V,4
/V PID , 5-a? /" 0/
OWNER
(Name) t / / LL JJ
b1a Nll ���
(Phone) 7u d - r - 131_
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(Address) /S s /. . a 1..4 .,/� //
a i _ ._ .4._... ,,
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APPLICANT
(Name) • /.� l�
e / _! f '47-771 _ _7(Phone) /�_-3_44
(Address)3 • a /
(Ad•ress) ar * , j 1 / -
(City) (Zip Code)
(Contact Person)
(Phone) L____S ' 4z-_ _
APPLICANT SIGNATURE 410
" DATE
IT APPLICANT PLEASE COMPLETE BELOW
ltieraniT t e of Fixture
111111111110 Bath Tub with or without shower T/t e of Fixture
Dishwasher ININMIIIII
_■ Rou:h-ins
__ Floor Drain
imitimmi1111111111111 Lavato Bathroom Sink Water Softener
-� Laun t Tra 1 or 2 coins artment sink ■_ Stand Pi l e Washin: Machine
_. Shower Stall Backflowewa E Asse
S�� Assembl
Bar Sink Backflow Assembl Test
_111 Water Closet ToiletEMENEMEI
1.11.11111111 Other
Industrial,Commercial&Multi-family 1%of job cost with a$EE9.50 CHEDULE
inimum Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
Estimated Cost $ i 6-0. Building Permit# I ne ivlinnesota 3tdtutes3 3Lnts..v-to
PLUMBING PERMIT FEE $ q,,S`(� "SURCHARGE"has been extended
STATE SURCHARGE $ The minimum surcharge for a
(Office Use Only) TOTAL PERMIT FEE $ "fixed fee"permit is$5.00
This Application Becomes Your Building Permit When Approvedi
T, - --• - .., Art
�;`id r SO Receipt No. y
Building Official Dat: By
Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 '
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372