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P NESO RI0 Date Rec'd
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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File PERMIT NO . o� �1
2. Gold City 7J`�
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS � 491) � I \r) e� \ n ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Na \aur W (Phone) 069 ` 16 LO
(Address) Y I Y oti I \'iead \,n
APPLICANT ' , ' / I Litt - t o
(Name) A 1` /l� �..'. �1 1 . A1 v� (Phone) -tow/
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(Address) �, I. • . , I
(Address (City) ' (Zip Code)
(Contact Person) \-0(1/1 (Phone)
APPLICANT SIGNATURE L I / ()I1 • <V q
A PLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain t 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 $ Lig, ¶•O
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
1 This Application Becomes Your Building Permit When Approved Paid w Receipt No 590 44„,0 Date`; U . /6 . c,/ By
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