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N CITY OF PRIOR LAKE PLUMBING PERMIT 57/ 3
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i. Blue File
z. cola city PERMIT NO. /3 05z3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
4 4 8 7 0 a/P L Tr) Ri
LEGAL DESCRIPTION (office use only) O ,` j �
LOT BLOCK ' ADDITION . , r J�, ` " gdu n i PID/15 / 3g -'0Q ,a-
( OaWNER V � 3 t/l A 4 (Phone) 7 / 5
(Address) S - YW 7r ( Q 1 1 i q
APPLICANT ( _ I
(Name) .A.40'
. W V A itio (w (Phone) (5 I '? b
(Address) �. • 0 � s f 6(.0 v
(Address) ( * ) (Zip Code)
(Contact Person) On 5 (Phone) 6 Z
APPLICANT SIGNATURE L1 1 DATE 5-21
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 $ vV
STATE SURCHARGE $ 0 .
TOTAL PERMIT FEE $ ird 0
(Office Use Only)
This Application Becomes Your .1 ding rmit f en Approved jl St Receipt No. 1 q/ q
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C3 Datr/ jz By ( f/ "/
Bu Offici: Date e l3( `l J /f
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
44V
5;ft+..
.