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,,ti: CITY OF PRIOR LAKE PLUMBING PERMI
+ ��- / 735 � � ' - I
*NES
1. Blue File
z. Gold city PERMIT NO. 09 036 c i
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
, E 01,otd I,10,. 1 i / .,,,,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ,....- �'
(Name) J ■ a /, C.. K c / ,/ (Phone) y Y 1- / y-e `/
(Address) /..5 , 3 G r H 01 1.4.1G 1 i-- e v F- a k t f- ' S 3 ?c
APPLICANT± (Phone) —/� V/. (Name) e .1 7 i'R j` 4 ! `s el C hone s
(Address) / 0 -- 0 ., fir 1"
(Address) 4 (City) , (Zip Code)
(Contact Person) (Phone) `3 ? — vi-yo `r .
APPLICANT SIGNATURE DATE et, 1/ /0 2,
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater
Floor Drain Water Softner
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family I% of job cost with a $39.50 minimum Residential, New One & Two - Family $99.50
Residential, Additions & Alterations $39.50
Estimated Cost $ //9 9 Building Permit #
PLUMBING PERMIT FEE $
1
STATE SURCHARGE $ � .50
TOTAL PERMIT FEE $ � 0 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Rec. -,t No. 7 . j ,
Date. By
4
Building Official Date , /1.0 -
24 hour notice for all inspections (952) 447 -9850, fax (952) 447-4245 ,
16200 Eagle Creek Ave., S.E., Prior Lake, MN 55372 - 1714