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( i1k.R.,,I,:24 Date Rec'd
Le CITY OF PRIOR LAKE PLUMBING PERMIT 9 / 4-i °
illiArNESO 1. Blue File
2. Gold City PERMIT NO. > 7 7g
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
2.03 ,3c /ti0 n/ i
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT �" c�
(Name) t__ c/ i /IA P1�) 930 C (Phone) (Q /7 * 23 2 -- 5SU /
(Address) /720/ �B12 -'Zs N R 1/ jbW MN 3 q Z
(Address) (City) (Zip Code)
(Contact Person) C c) 7--'- ! (Phone)
%2 APPL ICANT SIGNATURE DATE /`T //d
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 1� 1 , ,3
STATE SURCHARGE $ S (J0O
TOTAL PERMIT FEE $ ,5-4/ ,
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid / ' No. (i (36 7 sr)
Dater Al O•y •
Building Official Date ( `'7
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372