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P Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
9
11 /L'NES(P P /
1. Blue pile PERMIT NO.8 &
2. Gold city 47
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5q3 Cmf 5k S6
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER f ' ` -(0(8- [�(�
(Name) "Oh . .0 i i i V ( Phone ) �� ' 7 7` • S
(Address) S , l 'r c.�C� n (� ra' C , c__,
APPLICANT , /�Q
(Name) . 1 L� ^ 0 n e„. •Y YT d h (Phone) t CJ O
(Address) l I DO n 1 0 C./1Y 5l a- -� 0 _7121L li► 1 st-5T5 q
(Address) (City) ' (Zip Code)
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(Contact Person) a ', /Q. (Phone) a - M Se
APPLICANT SIGNATURE
■
; IL J _ _ _ DATE 1 ® 2 I 1
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
Industrial, Commercial & Multi- family 1% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
_ Residential, Additions & Alterations $49.50
Estimated Cost $ U) — Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ r' ,
(Office Use Only)
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This Application Becomes Your Building Permit When Approved 1 Paid G-� ` `�
Receip o ,
Date I By
Building Official Date ■ /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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