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9 o� CITY OF PRIOR LAKE PLUMBING PERMIT - Z ��--
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ar�IVNESOgr 3.V F et 1+ PERMIT NO. /5-63:5-2./
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3.Yellow Applicant
(Please type or print and sign at bottom) ZONING(office use)
ADDRESS I �� C�\d \ +� ! _, ,e��--372
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LEGAL DESCRIPTION(office use only) •
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LOT ' 1,0--LOCK / ADDITION 1,0-- ,11 ' 4 " PID7 1
OWNER Id enne:kil e (Phone) q5z .2a 16 1 j
(Address) 1141 I Dee Q_. T1i,C1 '-'0 Q 1 1'1L\O Q
APPLICANT Genz-Ryan (Phone) 952-767-1000
(Name)
2200 West Highway 13 Burnsville, MN 55337
(Address)
(Address) (City) (Zip Code)
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(Phone) 952-767-1000
(Contact Person) �„�J��j�
APPLICANT SIGNATURE ..@. DATE �//` <
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 SCHEDULE
The Minnesota Statutes§326B.1'48� r job.costwith a$49.50 minimum Residential,New One& o-Famil $149.50
" "has Residentta,Additions&Alterations $49.50
The miniSURCHARGEmum surchargebeen fora extended
. $ Building Permit#
"fixed fee"permit is$5.00
.PLUMBING PERMIT FEE $ 4 'SO
STATE SURCHARGE $ 0 5.00
TOTAL PERMIT FEE $ .5U
(Office Use Only)
No.
This Application Becomes Your Building Permit When Approved td 5 !J Q
Date �l k5 By �r
Building Official Date i� �
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372