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P RI Date Rec'd
2. Gold A
° CITY OF PRIOR LAKE PLUMBING PERMIT
l'�'NB SD�p
1. Blue City PER NO. 4)
O 9. 0,33
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5 ` fir at 111ectd LcIA„ .. kr- tor Lodee 55372.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) U.5 CO- r Ka Li re. ( Phone ) 6 12 61 8 11 Z___9
(Address) J 445 — FlrCL 1 I 1 ' 1 e l '' . e-- '- 44 i o Lake
APPLICANT
(Name) d.) r a t 1� P -P utev b t (4 q (Phone) 6 ? - 2_ r1 R (n ei q GI
(Address) C.)el r J` 2_0Q St. LL) .. Latz.e -vi1 to 55C 1 4--
(City) (Zip Code)
(Contact Person) De-1) or Vir 1 i (Phone)
APPLICANT SIGNATURE INIP1A d /L' DATE tP - O
APPLICANT P 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 1'V
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
l Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi- family 1% of job cost with a $49.50 minimum Residential, New One & Two - Family 8149.50
Residential, Additions & Alterations 849.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ 4R .5O
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 1/4 50 . 0 D
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 50 !, 0 Rece' No. 57995
Date 3 - : 0 9 By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E,, Prior Lake, Minnesota 55372
5o , 0 v