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PRIp Date Rec'd
,,, . e CITY OF PRIOR LAKE PLUMBING PERMIT
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11-111
I cola city PERMIT NO.0 9�
3. Yellow Applicant V / • / O�
(Please type or print and sign at bottom)
ADDRESS
I 1 N,R0,0 RO f-9(
ZONING (orrice use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OW NER \ (L& 1 \(6 i V D (Phone) ' 510
(Address) \,,a,(notoeiG0 0
APPLICANT , • �
(Name) \, �11,' i ► , _ I , f ' , I A ' . (Pho - ) .4404
(Address) r� "" "' �/� �1 - L/ 11 �:, '11�, : � d 1
(. ddress)
• n (City) ' (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE k I 1 1I��1/ ////` DATE t I
A ' ' LICANT PLE SE 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 $ (;
(Office Use Only)
I
This Application Becomes Your Building Permit When Approved Paid 6 - D w Receip o io_e
ri
Date By
Buildine Official Date i2, 1 (.0 C1 ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 `�
1. \ J J