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Date Rec'd
P Rj0
CITY OF PRIOR LAKE PLUMBING PERMIT -7. Z3 07
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INNESd� I. Blue File
2. Gold City PERMIT NO. 09 0
3. Yellow Applicant �
(Please type or print and sign at bottom)
ADDRESS . I ZONING (office use)
1 Le9 tp W I tom` 9 ) lircU
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
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(Name ( ) a 1 tt Ta , ' "`" Y (Phone) t NV'
(Address) 1 ug b WI 1 (AJC.- rrii2 JE; ' 1 ali
APPLICANT ' ea (Name ) to NI I1 t/ . (Phone) 5 I' 4
(Address) 1 ?)1 4) n t 111 or, %MERL T " `
(Address) (�`�
dress) (City) ( � (Zip Code)
LU (Contact Person) ' i) (Phone) "1,�J� `L4L� . `U ip .
APPLICANT SIGNATURE ` 41 ./ A . t 41 1 DATE 1 ` • CO
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 $ 1 10 11-0
4
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 1 50,6T
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid 50. co Receipt No.5- 44 _ 5 _
Date 7 Z3 0 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