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04 SP S�
�'� CITY OF PRIOR O
LAKE PLUMBING PERMITDate Recd
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'lease 1.aloe File
7�r�a or.Tint ands!; at bottom 2.Cold city PERMIT NO./�
ADDRESS ^ 3.Yellow Applicant
�j mert
���..JJJ 1�'NO ZONING(office use)
LEGAL DESCRIPTION
Le i---/ (office use only)
LOT BLOCK— ADDITION r� _
•
OWNER de,/. 74:,) P �"JJ'� O��
(Name) f' l-�sl C�, �`
(Address) 3-16 6c e• - P (Phone) _q62 �q--��,
APPLICANT J 1 _
(Name) Genz-Ryan
(Address) 2200 West Highway 13 (Phone) 952-767-1000
Burnsville,rnsville, M176-53-3-7------
(Contact Person) 4-ee,L (City)
(Zip Code)
APPLICANT SIGNATURE // / (Phone) 952-767-1000
--------,..7, DATE � 1 X1
APPLICANT PLEASE COMPLETE BELOW
T I e of Fixture
Bath Tub with or without shower Quantic
Dishwasher T e of Fixture
Roush-ins
Floor Drain ��
Lavato Bathroom Sink Water Softener
111111.111111.MEM Laund Tra 1 or corn.artment sink Stand Pi.e t r
Shower Stall _ Machine
Sewa:e EAsse
Backflow Assemb!
Bar Sink ............._111111111111.11111Backflow Assembi Test
�r Water Closet Toilet 11111111111.1
Tlte...._ ._... ..._._..___ Other
The-1n-Oesota-Stattites FEE SCHE
•"SURCHARGE"has b 326Bied. johcost with a$49.50 minimum
E
The inininnun surcharge e ond�cj residential New One&Two-Famil
"fixed fees, ge fol'a •
R.
esidentiai,Additions&Alterations ' 0
permit Is$5 Q $49.50
•
Building Permit#
PLUMBING PERMIT FEE $ )...L p_
STATE SURCHARGE $_....A.
(Office Use Only) TOTAL PER
NIIT PEE $ 5 O0
This Application Becomes Your BuildingPermit When Approved -�;�,.
PP
( 111
47 id /�q Receipt No.
IP
Buildine Official V h
-ThMOM late
By
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241sour notice for all inspections(952)447-9850,fax(952)447-424 I
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
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