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Date Reed
e:i CITY OF PRIOR LAKE PLUMBING PERMIT -.
1.4
3 Yellow retie PERMIT
PERMIT NO. /� o�03
41
tease type or print and sign at bottom)
IADDRESS ZONING(office use)
167 I q Ly 011 S S-E- . S
LEGAL DESCRIPTION(office use only)
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LOTS BLOCK ' ADDITION Z q9 ,D(; ,S4 MD O/7- Z
2 ei L,
OWNER C,, ,
(Name) La vl ek J (phone)
(Address) I (c'7 14 L---Lf olvi S keke S,
-6.-
APPLICANT .
(Name) .1 j M A it . (Phone) 96--
` ?9 S- 3 e 3 al
4,
(Address) • 9 9 Rd l ,. AlS I Osse SS 3 'q
(Address (City) (Zip Code)
(Contact Person) i g a_qS
,..,j� (Phone) �= G ,�
APPLICANT SIGNATURE A -Y'r ,,, DATE -N/3r
APPLICANT PLEASE COMPLETE BELOW
'
,'Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher l 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
'hie Minnesota Stattttes - FEE SCHEDULE
"SURCHARGE"has xdedg 105 cost with a$49 50 minimum Residential,Addittiia s&Alterations $49.50 0
The migi . Residential,New utn surcbeenharge forate $ 6o B
"fixed fee"permit is l0"
Building Permit#
r 1.00 -PLUMBING PERMIT FEE $ 41(1r 9)
STATE SURCHARGE $ r. 00 XXX j.0°
TOTAL PERMIT FEE $ , 57)
(Office Use Only)
This Application Becomes Your Building Permit When Approved &Man Receipt No.
, aN,'.
lDate By4• Buntline Official Date
\ _ e
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372