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F � CITY OF PRIOR LAKE PLUMBING PERMIT
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� " LEGAL DESCRIPTION (office use only) �
LOT BLOCK ADDITION PID
OWNER ,�•� / L
(Name) • d �L �tJ (Phone) '��j�''"G��� /7� �
Addr s � �n p / � _ � . - � � � �r' .e � �?" '� ,�' ",� . .:
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APPLICAN
(Name) (Phone�_ '� � � 0 ��
(Address) G :a b / �'( �� �.�.� .
(Address) (City) (Zip Code)
� (Contact Person) � L.--- (Phone) '7 �.�' �T/`,./�l.J ,�''�
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� PPLICANT SIGNATURE � "� DATE �~�
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� . � �APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture - Quanti T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink r .; 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 Gloset Taiiet ; ; �� , , Qther ° ,
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 #
` PLUMBII�JG �ERMIT FEE $ T Y. ��
� STATE SURCHARGE $ ...y - - �� �� ;�
; � TOTAL P�RIVIIT FEE $ � `' ', " ' � ,,., �
(Office Use Only) e '' �t �4
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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
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