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PRjO Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT , / q . / /
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4,INNESV�� I. Blue File
2. Gold City PERMIT NO. /
3. Yellow Applicant t
(Please type or print and sign at bottom)
ADDRESS f �� � v � C � I � � ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER L r 1 \ Y 9 U` • 3 I (Phone) LP IQ / co -0--77
(Address) ) , ---11 1 81, w c.A vc,/7,) tic, ) r )4
(Name) �� ► I (Phone) l 'ca- (--/ "l J --- `_/ 6 Li-
(Address) #' W, h 4� Q4 4104 Ck-loi $ SS-3
it (Address) (City) (Zip Code)
�) L/ L/ 1 41-/t/Li 1 41-/t/Li (Contact Person) g ,� �� /� �� _ (Phone)
9
APPLICANT SIGNATU • , ' G �C (/l_ , / P/ DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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 $ Building Permit t# #
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PLUMBING PERMIT FEE $ / ,`- 0
STATE SURCHARGE $ S 60
TOTAL PERMIT FEE $ ' (: Sb
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid 3 :6 Rece No. / Z y'Q .6
Dat- /g i ll By
Buildine Official Date ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372