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CITY OF PRIOR LAKE PLUMBING PERMIT , / & , / 0
41A'NESa *I¢ i. Blue File
PERMIT NO. /0 54
3. Yellow Applkant
(Please type or print and sign at bottom) " T �
ADDRESS ZONING (oince use)
3551 IS / 71/ lsi(v/ (K.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) R � O i U U 537 Q f( (Phone)
(Address) 3 5 1 Wand Vvvy P. 46t met
(Name) ANTA S f0(fa-lTC/ M'( (h Qrw7 l (Phone) / 11 v/ �'I S 510 D
(Address) PO "au Z5/ 5 ImK -C 1 71
(Address) C f 0 ( ity) 23-.51060
(Zip Code)
(Contact Person) `1 l , n 1 f- .+ .v (Phone) q 57 �
APPLICANT SIGNAT 'AP's _ �-�►� O� DATE
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 Elector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
1 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 $ 5 . C O
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5b t No ,060&
Building Official Date pate G- Z Z- o .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372