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CITY OF PRIOR LAKE PLUMBING PERMIT
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44 k'NESO
1. Blue File
z cola City PERMIT NO. /D 0657
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS take_ ZONING (orrice use)
733 � �i n ra c; (,'c ve le, Pr(o I /Y1 /II .55'37a
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Na � O Le r T 6 e0-e ` (Phone) 95'.q - c v o— / me)
(Address) / 9333 V i t h 1�G t re le Pk r 0 . Let kP lx 41 55157.Z.
APPLICANT nn /
(Name) CI IrOi y O�. (le ( O owa'tep- (Phone) '7/5 - _ 6 7
(Address) 3 4 / 4/ 0 /lee VQ/ / k /mac -PC/S G i'1 Id 1 5zio i
(Address) (City) (Zip Code)
(Contact Person) J 1 o'l gel-to V (Phone) 1/5 " (`7
APPLICANT SIGNATURE j6467 DATE 02/` /l0
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 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
'0
Estimated Cost $ l DO — Building Permit #
PLUMBING PERMIT FEE $. 5'6
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ SO • �' c
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5 ( A) Rec; . No. 3 V
� , . at) Date � / � By
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372