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° ; T CITY OF PRIOR LAKE PLUMBING PERMIT
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. Blue d clt F" Y PERMIT NO. / 0 , / / ` .
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I ti DV /746(60A) D r. 8E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER fi f i C1 feed (Phone) Z- 2-2-to - 51 0
Name �" � J',, / � J S
(Address) 1 ( ZI r7 pa /t VI ii v Ps , SE
APPLICANT
Nam) 71 � � r / S Z — . y 5 — Z Z
(Name) J a n� (Phone) / /
(Address) 2- 0 (),' 4 '/Z W WI'r fvi ? 1le 55337
- (Address) (City) 1 (Zip Code)
(Contact Person) / U (Phone) J 21 J - l'i L / ( 1
APPLICANT SIGNATURE J DATE 1 2 -1 1) 1,
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
Dishwasher i Water Heater
Floor Drain Water Softener
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 1% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ I 0 0 Building Permit #
PLUMBING PERMIT FEE $ 1 4'5+
STATE SURCHARGE $ 5 - OD -at
TOTAL PERMIT FEE $ 54 - 50
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid , / S - D R ei No. 0 (s Z d
Date //(C-• `/ QQ
Building Official Date v • (0 i •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372