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p PRO CITY OF PRIOR LAKE PLUMBING PERMIT Gold Date Rec'd
I. File PERMIT NO. /3,,
2. Gold City , c:: , 7
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS , e_ Fej� f - P,J1/ ZONING (office use)
( a 47/3 S
LEGAL DESCRIPTION office use
( only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICAN�T
(Name) S7' ma, P /4,-,7 (Phone) ( / 7D /` % 7 '
(Address) 6 �J � �� /w(' k i . 4 7`' l / 5-$iZ3
(Address) (City) (Zip Code)
(Contact Person) /!v /Q, it/es holaz.,
�/1 (Phone) �' / 4 70/ ' 9717
APPLICANT SIGNATURE �� / / " % DATE 6/77 /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 $ .50 0
TOTAL PERMIT FEE $
(Office Use Only) 512
This A 3 licatio B comes Your Building Per it hen Approved Paid Receipt No.
` Date By
Buildin O lc -- _- - - 4v to 6{1/(3 40
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372