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� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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. 1. Blue File pERMIT NO
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2. Gold City
3. Yellow Applicant , � i
Please or 'nt and si n at bottom
ADDRESS ZONING (ot�ice use)
1 � � 1�Vi � de,�rr��5 �Tr� I ��
LEGAL DESCRIPTION (ofl6ce use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone) � � � �
(Address) v 7 5
APPLICANT /;�,, ' � 7
(Name) cM / � (Phone) � i � .���._
(Address) � ' � `
( , ress) (City) (Zip ode)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE � 1 — 1 �
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fizture Quanti T e of Fizture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laund Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
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 #
PLUMBING PERMIT FEE $ `
STATE SURCHARGE $ . O
TOTAL PERMIT FEE $
(OfBce Use Only)
This Application Becomes Your Building Permit When Approved Paid �--� /� Receipt o. �! �--7 (� i1 _
`r (YJ i v y�
Date � � � � �� By
BuildinQ Official Date
24 hour uotice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 �� /'�' '' r�,
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