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4, CITY OF PRIOR LAKE PLUMBING PERMIT
A'NESO
I. Blue File PERMIT NO
2. Ye City NO. p 3 �— 3/
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 i 93 S i f 1 ■cr /1` („)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( C/V CN n it/ V V A-1- (Phone) ) 2-- P - 9 ) - `3T
L \I
(Address) 3 rr J74) \ f/ , {A, 31 A C�- AAA,) (j'L
APPLICANT 2 4:2V S 11- 91
(Name) ) �- l CV V�nT'�( (/✓t�IeyC C- d'��J) � (Phone)
(Address) 3 0)- 7 1
(Address) (City) (Zip Code)
(Contact Person) J ( v7 N - (Phone) 3a 69 ~ s�3-
APPLICANT SIGNATURE � DATE q '- ) 3
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 $
STATE SURCHARGE $ ,17 61Y
TOTAL PERMIT FEE $ S-/, S [r
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paidr_ A � Receipt No. � �
�-�y
fl �7 3 Date By
Buildine Official Date ✓ % - / > ��I�
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372