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e: 9 CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2 Gold City PERMIT NO . O .
. V 0010
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 7 1 80 Toro IA o Ave ,S.E.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) A.N Gu () 5 (Phone) Q52- 830 9 OS'+
(Address) 17 1 8 0 1 O i c'i tO Ave-, 5E*. t Pr f o r Lake
APPLICANT
_
(Name) D (a 4 H -Pro P/ u t...� t �j (Phone) �7 �o 691
(Address) 88 E 2_09P-43A . SE . 0-) - L Q Lev 1� P� 5 ��� T
(Address) (City) (Zip Code)
(Contact Person) J e (Phone) � 'o c( & R R l
i
PLICANT SIGNATURE - Li / / DATE (' 7. 00
APPLICANT ' ASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type 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
FEE SCHEDULE
Industrial, Commercial & Multi- family 1% of job cost with a $39.50 minimum Residential, New One & Two - Family $99.50
Residential, Additions & Alterations $39.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ 3 ci .60
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only) 46 • 0 0
his Application Becomes Your Building Permit When Approved Paid A O Rec t No. 551 2.... (
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Date ` � J •
Building Official Date I. O
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
16200 Eagle Creek Ave., S.E., Prior Lake, MN 55372 -1714
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