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CITY OF PRIOR LAKE PLUMBING PERMIT
o w F g e ty PERMIT NO. /
3. Yellow Applicant _ O q sr'
V e 5ri (Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 3
LEGAL DESCRIPTION (office we only)
LOT BLOCK ADDITION PID
OWNER
(Name) "i G S _ (Phone) t� 1 " ( - 6 ) 3 c3
(Address)
APPLICANT
(Name) T v4 `F' l u LA 1(1.4 -. c . (Phone) 5:y7_2-0 L- f M t 9
(Address) Cf t a rc%carci Anci3‘.- ri 6clu t- of,,, 1 %z 2_l
(Address) (City) (Zip Code)
(Contact Person) �`�,'1P S ✓�, �l hone) rn
APPLICANT SIGNATURE DATE ) O -:D
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater 1 4-0. 1 030
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 $ Building Permit #
PLUMBING PERMIT FEE $ Ei
STATE SURCHARGE $ 5 .50
TOTAL PERMIT FEE $ , c e ) G ,
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid52/ R 'pt No. G /6 , 42_
Building Official Date Date , 2- 7. / d
24 hour notice for all Inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372