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,� P CITY OF PRIOR LAKE PLUMBING PERMIT / z 3 O 07
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12. Blue r i l e PERMIT NO . ���]]]
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3. Yellow Applicant / r /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
St-C 1 0 Thr ---—._.. r _ v - - - . E75
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER R ��1 // S� -ems (Pho ne) 95�`gS - 76 77
(Address) 57.e / 0 1-- ' s 1— (7 ki-- y J F ( p ) _ S
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= * /?o � / /;z& (Phone) `-f 7
(Address) /Z(QD 11 G S 1
Address � � / 1 �� /�'C/ P2- CC ` .6 - 1._
(Address) (City) (Zip Code)
(Contact Person) i , 4 C 1 / a...... ' hone) 4C
APPLICANT SIGNATURE �� i _DATE /.:?1 ? 2
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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 -2 S e)
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ cc> , "'—
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid 5-0 0 Re 111, No.. 1 -
Date By �
Building Official Date 1 Z , 3 0 ,d
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -42 5 40
4646 Dakota Street S.E., Prior Lake, Minnesota 55372