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CITY OF PRIOR LAKE PLUMBING PERMIT
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i: coi ary PERMIT NO.
3. Yeilow Applicant /� • � Z �
ease or t aad ' at bottom
ADDRESS ZONIl�IG (o�ce �>
27� - I ��
LEGAL DESCRiPTION (office use onty)
LOT BLOCK .ADDITION PID
OWNER � `�
(Name) '� (Phone) ���` I'Q� ��
(Address)
���,, r� � �r � h�1 � 53�7�
APPLIC ` j � ��� r � � 7 V
(Name) / I�- hone) (e C��
(Address) ' a � � / �+ �� ��
Address} ( ' ) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE 1 ��` �O -1 �
APPLICANT PLEASE COMPLETE BELOW
uanti T e of Fi�ture uanti T e of Figture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e Washin 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
FEE�SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 mthimum Residential, New One & TwaFamily $149.50
Residential, Additions & Aiterations $49.50
Estimated Cost $ Building Permit #
PLLTMBING PERMIT FEE $ ���
STATE SURCHARGE $ :'�0
TOTAL PERMIT FEE $
(om�e u� oo►y>
This Appiication Becomes Your Building Permit When Approved Paid �C` 1 � R e' t No. 67� ��'
7
Date ` �� Y �Z_ y
Buildine Off[cial Date `
24 hour noHce for all jnspections (952) 447-9850, tax (952) 447-4245 �
4646 Dakota Street S.E., Prior Lake, Minnesota 553T2
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