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�F PR10� -llaate Rec'd
�'� � CITY OF PRIOR LAKE PI�UMBING PERNIIT
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1. Blue File
3 Y°'� c`� PERMIT NO. �3�0 J��
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ADDRESS ZONII�TG (o� use>
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LEGAL DESCRIPTION (o�ce use only)
LOT BLOCK ADDITION pID
(Name) ��C � � � S r �, V e � (Phane) �,7r°'1 ' L�l�'f�- f5n �f �
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APPLICANT J
(Name) _ �� 1`O - � C�� �' � , (Phone) � �O 3- �l �l- � jl1 �/
(aaa�� ��f 53 U' � 7 l�- ve f� (� l� h1ot�.�?I Y{'l «-' jS �/��
(Address) �. tcitY) (ZiP Code)
(Contact Person) � � e L, a j� h .,, a . � OS 839 / �hone) ?6 3- Sl 5' - 3 9 0¢
APPLICANT SIGNATURE ' � . DA� f�/1 �� �
APPLICANT PLEASE COMPLETE BELOW
nanti of Fiatare anti of Fgtnre
Bath Tub with or without s�iower Rou ins
Dishwasher Water He�ater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi Washin Machine
Laun Tra 1 or 2 com ent sink Sew e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet pther
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a 549.50 minimum Residential, New CMe dt Two-Family 5149.50
Residential, Addirions & Altetations $49.50
Estimated Cost $ g � �, �� Building Peimit #
PLUMBING PERMIT FEE $ � S c �
STATE SURCHARGE $ Sff�
TdTAL PERMIT FEE $ �'
�offi�� u� onty� �j='Y s v
This Application Becomes Yoar BuildiBg Permit When Approved Paid ��� Receipt No. 04
0
Date / J By �
Btildin¢ Offieial Dah
24 hour notice for all inspections (952) 447-9850, faz (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota SS372