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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
l NNEso
I. Blue File
2. Gold City PERMIT NO Q j��p OG7'
3. Yellow Applicant V
(Please type or print and sign at bottom)
ADDRESS 56 / 0 �� /`� - � % � ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID Z Z b7. Q O Z c)
OWNER
(Name) S C 0 7T S 1 u e (Phone) c WO S 0
(Address) 3 (p / 0 f 0 YCS / C t'' f • S. E .
APPLICANT f / / cis l
(Name)
APPLICANT/ 1 1 6 v'' C. he: ; / , I/ fl (Phone) %S ✓� - Lf / 35
Address / S .. h & S53
f�
(Address) S
44 e ,11(Address) . /2 0 rj 0)( (City) (Zip Code)
(Contact Person) R 0 d e (Phone) qS '
APPLICANT SIGNATURE /r� ' tee__ < DATE O
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 1 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 ''
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 57) ( )
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5v vU Rec i No. 76
Dat B
Building Official Date ' ' Ob •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372