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ID CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue PERMIT NO .
2. Gold City .
3. Yellow ow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) /4 AA S h-C V"\ b D (Phone)
(Address) I LI /c/ S S 41,4 C ( i ✓ c-, -
APPLICANT
(Name) CJo & J46n P iv M b (Phone) IS Z- W 315 a
(Address) f• 0 ' 1) 4-- 1 Z S 1 2 C i b( CC- Q.-K._ in (57 - 1 Z
(Address) (City) (Zip Code)
(Contact Person) TO (--- .'Z— (Phone) ‘/Z — 270 6' I Z
APPLICANT SIGNATURE � ` � - DATE 7 - 3° ^ / 3,
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I Water Heater
Floor Drain 1 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 I% 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
"SURCHARGE" has been extended $ Building Permit #
The minimum surcharge for a r
'LUMBING PERMIT FEE $ 4 6 1 .. c
"fixed fee" permit is $5.00 ;TATE SURCHARGE $ .500
TOTAL PERMIT FEE $'S'c)
(Office Use Only)
This Application Become - Your B ilding Permi Whe Approved Paid Receipt No.
GA 5
OA — 1, Date 5— By
Buildine Official Date 1 „ m 0---
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372