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� "'�� '�°�, � CITY OF PRIOR LAKE PLUMBING PERMIT � � � , � -�,_
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,. B '"` F "e PERMIT NO. 9 /��
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3. Yellow Applicanl
Please e or '# and si at bottom
ADDRESS ZONIl�TG (office use)
�f �� �'� � N �a � l -����
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�aWNER ��� � � � � C 1 � K e V 1 C }'� _-- (Phone)
{Address) � ��( � � �.�� � {�s'�S
APPLICANT � � � n A ��� P /�.i l ' �j /�k
(Name) f"� C� L (Phone) J��' C�
(Address) l� 2 -� cO � S"}" I V w L V�� ��� U(�� � W��
(Address) (City) (Zip Code)
(Contact Person) �--� v�� � (Phone} ��� — ��� ��V��
APPLICANT SIGNATURE DATE ` O � 2
PPLICANT PLEASE COMPLETE BELUW
Quanti T e of Fixture uanti T e of Ffxture
Bath Tub with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink) Stand Pi e ashin 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 flther
FEE SCHEDULE
Industrial, Commercial & lvlulti-family 1% of job cost with a$49.50 minunum ResidenHal, New One & TwaFamily $149.5�
Residential, Additions & Alterations $49.50
"fhe Minnesota Statutes § 32G.F3.148 � �st $ $uilding Permit #
"SLtiZC.l-IARG�" has been changed for one
ye;ar effective PLUMBING PERMIT FEE $ � 9��U .
.DuCy i, 2040, �u�til,7une 30, ZOt i. STATE SURCHARGE $ ��'�� -
'Phe minimum s�irchargc for a °Eixed fee" permit TOTAL PERMIT FEE $ �� � sU
is �, begim�ing.iuty 1, 2A]0
This Application Becomes Your Building Permit When Approved Paid �� �--U Rece' t No. /_� i/ _
lp y �
Date /
Bailding Ofticial Date !l- �-- � �--
24 hour notice for all inspections (952) 44?-9$50, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mlnnesota 55372