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C, Date Rec'd
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, °` m ey CITY OF PRIOR LAKE PLUMBING PERMIT 1 Z 1*- b7
-4-ti, 1. Blue File r �
2. Gold City PERMIT NO.0 (� / UZ c"
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
33 00 Street'
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name) ,� awl d if v' n1 l/'''f l it (Phone) (`7 5Z) Lf L / - s
(Address) i
APPLICANT N l( h 1 0 �il �C i a r �/ 1 19 l n { Q74. ' / 03 Ti
(Name) v G i l/ v f i v tM t 1 : (Phone) (CP /Z) S �C ✓
(Address) !� t O J v"' " ' `'t f/i- , ' {5 - pis 0 K
(Address) (City) (Zip Code)
(Contact Person) - (Phone) COA 2 —) 0-7-
APPLICANT SIGNATURE 4 --..— DATE _1491:0
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
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ #1,5k
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 50 , p'o
(Office Use Only)
I
This Application Becomes Your Building Permit When Approved Paid 5 CV Rec t No.SCi &G
Date
/Z ./ c�
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