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(.(pRfi Date Rec'd
'° e CITY OF PRIOR LAKE PLUMBING PERMIT 4, , /S /1
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'. Blue File PERMIT NO .
2. Gold City //, asy
3. Yellow Applicant '/!/
(Please type or print and sign at bottom)
ADDRESS �j � 4mowJ- ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER PC .�, 9/`yl
(Phone)
(Address) "7601 F'}1( t CAV NW
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APPLICANT
(Name) Ai "3 l i a n: (Phone)
(Address)
(AddfW . ".,:: , (City) (Zip Code)
4
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE
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 $ 9 Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ _ .50
TOTAL PERMIT FEE $ 1J 071
(Office Use Only)
I
This Application Becomes Your Building Permit When Approved Paid 5 j Rec • No. 2.5-41
Date ., /b , , f/ B
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
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