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e CITY OF PRIOR LAKE PLUMBING PERMIT
' G F1 PERMIT NO. //,,
3 . Y City ' / v
3. Yellow Applicant t�
(Please type or print and sign at bottom)
ADDRESS + , . ( g � ZONING (office use)
Red
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
•
OW e) 1 ' { I O C.tl€. \ (Phone) ® 1_01A 13 5c 5
(Address) ) $ ' Re_CA oQ S Rd V
APC (n� �(� / , ) I � (Name ANT � GSV - l R. gCK 11 ►C� (Phone) ") I /J - " 1- '
(Address) `2-0 1 •
4AM-I (Adddr�` . esss) , (City) ' ( Code)
(Contact Person) (7-) iC (Phone) 95a - L� `- 1L �1 L L)
APPLICANT SIGNATURE -4 DATE / ? - z 7 - v/
APPLICANT PLEASE COMPLETE B ELOW
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 I% of job cost with a $49.50 minimum Residential, New One & Two - Fancily $149.50
Residential, Additions & Alterations $49.50
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Estimated Cost $ 15 Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ hp
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid y � Receipt Ito. - / d
Date J Buildine Official Date /Z Z Z .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E„ Prior Lake, Minnesota 55372