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Date Rec'd
RIp
om CIT OF PRIOR LAKE PLUMBING PERMIT ' _5`, ,, U 7
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1 N i vESO�� ' / ( l / � z: o o i a c � i y PERMIT NO o9 0 z . , 0 0 \
✓ `� 3. Yellow Applicant
(Please type or print and sign at bottom) ✓
ADDRESS ZONING (office use)
I- � M
3 y
LEGAL DESCRIPTION (office use only)
PID
LOT BLOCK ADDITION
`t OWNER � k s 1 tijc-- (Phone)
(Name) � l
(Address) Slik---44k " ni t
APPLICANT , 6,4_, l f (Phone) 9J - -7 G `
(Name) 0 i ll,lZ�.l S �' I� �� 33 �
(Address) /f3 u ' ( (Zip Code)
(Address) �/
(City)
��, � / (Phone) �' cZ - x°1 - T� �
(Contact Person) ��� ' ' ` �
DATE C "l ° /
1, APPLICANT SIGNATURE i
APPLICA PLEASE COMPLETE BELOW Type of Fixture
Quantity Type of Fixture Quantity yP
Bath Tub with or without shower Rough-ins
Heater
Dishwasher Water Softener
Floor Drain Stand Pipe (Washing Machine)
Lavatory (Bathroom Sink) Sewage Ejector
Laundry Tray (1 or 2 compartment sink Sewage
Assembly
Shower Stall Backflow Assembly Test
Sinks �, Lawn Sprinkler
Bar Sink Other
Water Closet (Toilet)
FEE SCHEDULE
Residential, New One &Two- Family $149.50
Industrial, Commercial & Multi- family 1% of job cost with a $49.50 minimum Residential, Additions & Alterations $49.50
Estimated Cost $ 3e - e'er Building Permit #
PLUMBING PERMIT FEE $ .50
STATE SURCHARGE $
TOTAL PERMIT FEE $ SD • cN
(Office Use Only) Rece o. s77 1
This Application Becomes Your Building Permit When Approved Paid 57i
Date .� v � B
Buildine Official Date !/
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372