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CITY OF PRIOR LAKE PLUMBING PERMIT
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7/-
dt�SO�� t. Blue File Date Rec'd
2. Gold city PERMIT NO./2- 77/
3. Yellow Applicant
(Ple or print and sign at bottom)
ZONING (office use)
3(0 (09 o
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER .�--2 9 d - J 9.4
(Name) -.1....J � (Phone) 6�
(Address)
AP S CANT `- 4If1 (Pho ne) . �� � Gl (/ �Q � /S/
dres n / Z eik,40 44 N I , 4 wd'
(Address) (City) (Zip Code)
Tact Person) 1 d -&—ckA (Phone) 6 1z,— fc d-- e vi r
c A. 1 }C NT SIGNATUR tat' ' ' ^
it �, r "i' a
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
The Minnesota Statutes § 326B.148 $ Building Permit #
"SURCHARGE" has been extended
The minimum surcharge for a PLUMBING PERMIT FEE $ Ycl O 0
"fixed fee" permit is $5.00 STATE SURCHARGE $(; .50
TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid 5 s--z) R ipt No. , Q / G /
Date . (9_ r
Building Official Date S
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372