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PR Date Rec'd
° CITY OF PRIOR LAKE PLUMBING PERMIT �..�
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JNNESC, I. Blue File
2. Gold City PERMIT NO. 09 O¢e/
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
54 o z awn Meadow Carve.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O
(Na `7j _ '( rd (Phone) (011 0 0- 1 l f a
(Address) 3____ ?ri or 1,6 ke , IMF N . 5537 )----
APPLICANT
(Name) (Phone)
:,r iu, npion
(Address) 651- 365 -1340
36Witi 4j;d. #106 (City) (Zip Code)
Eagan, MN 55123 -133
(Contact Person) - S (Phone)
APPLICANT SIGNATURE „f �!'.r DATE
(, -30- 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 $ 4 q. 50
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ G j O. 00
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid eipt No. 1 _
5�, 33
Date . y
Buildine Official Date 1- d i
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
3 9 3 2f
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