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( fO CITY OF PRIOR LAKE PLUMBING PERMIT 5:, /.-
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I. Blue File
2. vela Arty PERMIT NO./3 4/3
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3. Yellow Applicant `
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5s Q1/4A teir- eea I e 0 „-- LAS, PAN) s 3 -72,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID 2 o 37 , 60¢ _ 0
OWNER ` VS/ - 7 Z e' ' 7 (Phone)
(Name) " `/
(Address)
APPLICANT r ,
(Name) v 1/ % (Phone) 9 S z.--Li Li `7 ` 34" '3 3
(Address) /Ole
(Address) (City) (Zip Code)
(Contact Person) 9.'&--- (Phone)
j . VGNA - - 0 AL DATE -s- l `-( / 3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwashers 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 I% 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 $ it -f 7 >
STATE SURCHARGE $ S. e'C
TOTAL PERMIT FEE $ S7 s2>
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid - S -- Z Rece' y o. 6 b 7
Date 5 ,---, /46, By
Building Official Date �� i .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 i
4646 Dakota Street S.E., Prior Lake, Minnesota 55372