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Date Recd
0 �Ar� CITY OF PRIOR LAKE PLUMBING PERMIT
v
+YNBSO'c 1 ooW T I PERMIT NO. /0 . l50
3. Yellow Applicant
(Please type or print and sign at bottom) ZONING (office use)
ADDRESS
20 13 r oO L._)0o(V (Z�
•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER t ��J i (.-__Ax l; .y,e S 01 ' (Phone 1 Z) 3 z —7 — q 9
(Name)
�—"`'
( A d d r e s s ) 207 eciy, vj C G C Q e-b Q Y" \ O q(
APPLICANT
(Name) ({.tk{ p3- (Phone) 6 7 S -3
(Address) ZC(C ( TV, Oil V of St 6ecio,, 0 t I t'I
Address) (City) � ( 1 Zip Code)
(Contact Person)
d , (Phone) 06' 75 3'1 6 �
APPLICANT SIGNATURE _ .� �.. DATE 5 Z e /0
APPLICANT PLEASE COMPLETE B ELOW
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 $ 366 19 ' (--- Building Permit #
PLUMBING PERMIT FEE $ t/ P : s
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 50 i o(
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid S vo Reeeip o. & OS Z f
Date, _ . 3 , b By
Building Official Date UG
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372