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l e e CITY OF PRIOR LAKE PLUMBING PERMIT
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4 vESO `cr 1. Blue File
2. Gold City PERMIT NO. 4 3 _.. / /
3. Yellow Applicant / �v
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
33S Maio - 4N
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N CR b � --- , (Phone) /2i ---- 60 3
(Address)
(Name) di5a � , Q„ (Phone) U/. �g PO' d' a `Z /.i .---)
(Address) S 1 Z 0 i At /VP JYom/ ~ 9
(Address) �) 1 An (Zip Code)
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(Contact Person) ��� �� " � "� (Phone)
APPLICANT SIGNATURE DATE 2-/-- at).- 8
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 ) 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 $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ - -(2
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid [' /so Receipt No. f 9
Date / 7 vie 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