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CITY OF PRIOR LAKE PLUMBING PERMIT
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411 1VNESO p I. Blue . File
z. Qo1d w App licant a PERMIT NO. 10 33 if
3 Y =ow /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3g6c) 54 /io A 4
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER /" i7V6,7 er 7L (Phone) ) / ' a 24'° 4i L)
(Name) �
(Address) 3 e /> /2/ /1/ Pri'id r L- m 5 S3 7 )—
(Name) APPLICANV ‘ v\ C._ /'J-£'x Gt Y1 K 11 hone) —Z 1 2 J Z S
(Address) " G� ' / �i� . S �/ . ' '' - j ig! $ Z 3 P 7
(Address) (City) (Zip Code)
(Contact Person) ( /2 4-eE (2 s) (Phone) gN.� �- r' 4
APPLICANT SIGNAT --t_'_ DATE S /1
/ 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 1 Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (I 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
f�� Residential, Additions & Alterations $49.50
Estimated Cost $ 1 ' l " C Building Permit #
PLUMBING PERMIT FEE $ «9 J
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 50. crii
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 6?) vo c ipt No. // __ o ( G
l�'
Date ( 0
Bultdine Official Date •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E,, Prior Lake, Minnesota 55372