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CITY OF PRIOR LAKE PLUMBING PERMIT
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�. 8�,� File PERMIT NO. � Z, � Z�
2. Gold Ciry
3. Yellow Applicant
lease or ' t and si at bottom
ADDRESS ZONING (og use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
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APPLICANT r/ �� �([(�
(Name) �����;� ��� I�uo�i (Phone) � ' �� �� ' " - � �
(Address) ����.1 w ����� �'� G����
(Address) (City) (Zip Code)
(Contact Person) (Phone) ������ `� �'t �
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fizture uanti 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 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-F $149.50
Residential, Additions & Alt ��� $49.50
Estimated Cost $ r-�( , 5D — Building Permit # �
PLUMBING PERMIT FEE $ _ � �
STATE SURCHARGE $ � �50 �
TOTAL PERMIT FEE $ �j�Q(� �
�ot��e use ooiy)
This Application Becomes Your Building Permit When Approved Paid ���-� Receipt No. 7' /�
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Date ��/ � / B _.--
BuildinQ Official Date j y�
24 hour notice for all inspectious (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesot� 55372