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4 PRrp Date Rec'd
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�, i��`, � CITY OF PRIOR LAKE PLUMBING PERMIT
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2: �� ��, PERMIT NO. I z-' J ,�,�
3. Yellow Applicaa
Ie3SC O! T1IIt a[id 3t �10tLD1II
ADDRESS ZONING (ot�ice use)
(1a� ���` c� � `
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PjD
OWNER �+ ��r �
(Name) � �'Y,��L l/ � (Phone) --�Z ���" ��
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(Address) G /"'� / /� /" � '
APPLICANT .
(Name) (Phone)
(Address) �� W A �
(p ��� (City) (Zip Code)
(Contact Person) � (Phone) ,
APPLICANT SIGNA U E � /
APPLICANT PLEASE COMPLETE BELOW
nanti of Fiature nanti of Fiature
Bath Tub with or without shower Rou -ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e ashin Machine)
La.un Tra. 1 or 2 com ent sink Sew e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
� g� S� Lawn S rinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commerciai 8c Multi-family 1% of job cost with a$49.50 minimum Residential, New ()ne 8t Two-Family $149.50
� Residential, Additions & Alterations 549.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ L��7 , S�
STATE SURCHARGE $ .50
TOTAL PERNII'r FEE $ ' � � S�
(O�ce use ooly)
This Application Becomes Yoar Buildi�g Per�nit When Approved Paid �, f� Receipt No. ��//�
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Date / ., /� j � By ' �
Bnildin8 Official Date y /
24 hour notice for all inspecbions (952) 447 9850, fAZ (952) 44'7-4245
4646 Dakotu Street S.E., Prior I.ake, Minnesota SS372