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OQ PRION Date Rec'd
CITY OF PRIOR LAID PLUMBING PERMIT
+ so*
I.:Ted FII` PERMIT NO. /4" 75-e,2.cold city
3.Yellow Applicant
(Please type or print andsign at bIottom)
ADDRESS 15 i ZONING(office use)
F>() --1--trn as \ U .)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER 0\o Q 9 f�(�� i
(Name) (Phone) Le12- �J I -0* 1(Address) \53i. \ . O rr) Ties N W
APPLICANT Genz-Ryan
(Name) (Phone) 952-767-1000
(Address) 2200 West Highway 13 Burnsville, MN 55337
(Address) (City) (Zip Code)
(Contact Person) Autu
C
(Phone 952-767-1000
APPLICANT SIGNATURE L) v e ,�/ )
*� DATE 8/ li i -S---
APPLICANT
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher C) 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
The Minnesota Statutes FEE SCHEDULE
Minnesota
§326B 1'48 j joli cost with a$49.50 minimum Residential,New One&Two-Family $149.50
"SURhas been extended . ' Residential,Additions&Alterations $49.50
The minimum surcharge for a
"fixed fee"permit is$5.00 $ Building Permit#
PLUMBING PERMIT FEE $ L` SO
STATE SURCHARGE $ I .(30 XXX 5.00
TOTAL PERMIT FEE $ SO,--T-)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid , Receipt No.t).„&)„,...7
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i../Official Date Date �E ,,A � By
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.R.,Prior Lake,Minnesota 55372