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, � pRl Date Rec'd
� �� CITY OF PRIOR LAKE PLUMBING PERMIT
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�INNES��� 1. Blue File
2. �o,d �;t PERMIT NO.
3. Yellow Applicant � � �
lease e or rint and si at bottom
ADDRESS . ZONING (oflice use)
� ��`� ��� � �
LEGAL DESCRIPTION (oflE'ice use only)
LOT BLOCK ADDITION PID
�aWNER 1 �� (Phone) � � �/ � 3� �
(Address) JG�/VY� '�- �� l7 ��
APPLICANT CI1a11'1V'=`"�?'" . ,t�'Yi 1fJ�
(Name) # �� ; �:i'°.�-�'�t�/I (Phone)
g�� _:�,:�-:,.- �'
(Address) 3�,? 4� : _, :' � RC4.
(Address) ��� !"' (City) (Zip Code)
� �1
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE �
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanti T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher er
Floor Drain Water Softener
Lavato Bathroom Sink an i e ashin Machine
Laun 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
FEESCHEDULE
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 $ �
TOTAL PERMIT FEE $ �
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid � Re e� t
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Buildina Official Date Date � �� Y f� B
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24 hour notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372