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(1) CITY OF PRIOR LAKE PLUMBING PERMIT K.,
NES °�� 1. Blue File pERMIT NO ` (`���`'''jyy
2. cola City / 2 �/ (,�
3. Yellow Applicant / J tJ [ �( �f
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 %1 / 20 tfrk s !— sue,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � z _ . z 3 7 — !2
(Name) (Phone)
(Address) 3 S G ! 7 U S~ S c..l to e- c:7 e I_-G Y z ,..t,t SC T
APPLICANT / Y //�
(Name) BO C'_ (,x`'14\ Pl 1114 hm (Phone) �-lO 371 2
(Address) PO ' 60 S- / 2S- 7 Kt 'o( Let 1- 4 SS
(Address) (City) (Zip Code)
(Contact Person) > (Phone)
X72 - Z7c) — 6F7 Z
APPLICANT SIGNATURE tr DATE ? /�(� / 3
A PPLICANT PLEASE COMPLETE BELOW
Quantity T ype 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 JMBING PERMIT FEE $
The minimum surcharge for a ATE SURCHARGE $ 0
"fixed fee" permit is MOO TAL PERMIT FEE $ ���
1
This Application Becomes Your Building Permit When Approved Paid S 1ipt No. � I t
BuildinE Official Date Date g 1 . 1 16
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 ,
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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