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4 PRI� Date Rec'd
p 0, CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Glue File PER NO.
2. Geld City a391
(Please type or print and sign at bottom) 3. Yellow Applicant
ADDRESS ZONING (office use)
3607 1 1.ss / /J
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) C�tr' CX I �,C [ ij ! Cl,( (Phone) ( 2)''S
(Address) ,...%07 t .4 / V l.!) 1 e( Lic s 72 0 7N)
APPLICANT
(Name) ¶ C� C-.■ 2 ec.A 0 C .,3 Q v
(Phone)
(Address)
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE/ 4 DATE c / o /ZD (
/� -
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 K Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink if So . — t 20 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 $ 11 vv Building Permit #
PLUMBING PERMIT FEE $ 4i- y
STATE SURCHARGE $ 5
TOTAL PERMIT FEE $ 5 T
(Office Use Only
This App2�. , o , ti. comes Your Building Permit Whe Ap! oved Paid /J Receipt No. g g
r++.•u•rr. e� /c� /� BY
- r �, te
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 j
4646 Dakota Street S.E., Prior Lake, Minnesota 55372