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( ---iillic.; Date Rec' d
. � e CITY OF PRIOR LAKE PLUMBING PERMIT
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Ii'NESO'c
1. Blue File PERMIT NO. 1 D, 6 �..3
2. Gold City
3. Yellow Applicant
(Please type or print and sign at botttoom)�)
ADDRESS
Y1)� \ J lX \1 c ) I � ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER SA Of fin (Phone) ';9 O ' � , I J r
ame
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(Address) / / M 4 iCktI f\il,
PPLICANT ,� a Y r J • (Q � (Ph one) L . Li `"l �l , `I 9
ame Vk) C n\it, .kin q
(Address) I Pal - I I �'� l
(Address) (City) (Zip Code)
(Contact Person) l r A (Phone) / T
APPLICANT SIGNATURE NAM . , DATE ,/ 3! `
ir
APPL CANT PLEAS COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain I 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 $ JV .
(Office Use Only)
This Application Becomes Your Building Permit When Approved 1. • V L i q E i 1. eceipt No.
I ►at %PR 1 5 2010 11 Buildine Official Date II'",
24 hour notice for all inspections (952) 447- ii 0, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, I ■∎ ,1..w,t.:.w* 74.