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10/01/02 TUE 08:19 FAX 6124475 CITY OF PRIOR LAKE 0753 10003
Date Rimc'd
Ot P R���
f e. CITY OF PRIOR LAKE PLUMBING PERMIT
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1, ted ci2:H I PERMIT NO( 3 -^-j,-, el/
3, Yellow ppliaurt l
(Please type or trint and sign at bottom) ZONING(oft=use)
ADDRESS ' e s /"iek �.Lco LErr
K:G11.5T ) JE CO evtwl c9Air v- P,ercle _ 4 1 fA
LEGAL DESCRIP'T'ION(office use only) J •
LOT a�LOC ' ADDITION prok /U I ciQ (le f _ Pma6-- 3 9/- CSD 3--0
OWNER 9 5-42- �f3 6-Z�9 p
(Name) )C6` -'IJ5TortJE C�nA.M J J 77 S (Phone)
(Address) S 9._to Ztj.Z-C-,SO 5i /kd_ .&oz-TE -O Cbleth¢'1 Ill SSYGg .
APPLICANT (Phone) l0�! '���T"/O�o /
(Name) 0 . - a L/ .• ;u., .a p
(Address) 5& P cAi r ,,4d ST. Iiuc .S-SI(Z
(Address) '
(City) (Zip Code)
ontact Person) ran 17&l N (Phone) _ G�SI- `� 7' o I
LICANT SIGNATURE 1/,Aa/ •� DATE S- .1- C 3
APPLICANT PLEASE COMPLETE BELOW .
Quantity Type of Fixture QuantityType of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain Water Softner
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
` a" T12-.1ex41,41'te.4/ 4J4-7 72 f)1E'lm
FEE SCBEilk.E
Industrial,Commercial&Multi-family I%of job cost with a $39.50 minimum Residential,New One&Residential,Additions&Alterations Two-Family $39.50
•
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $
STATE SURCHARGE $ - .50
TOTAL PERMIT FEE $ filo•"'
(Office Use Only) •
his Application Becomes Your Building Permit When Approved Paid _- Receipt o.
fr
pate Q 13 _
Building Official Date Date
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24 hour notice for all inspections(952)447-9850,fax(952)447-4245
16200 Eagle Creek Ave.,$.E.,Prior Lake,MN 55372-1714