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04 PR10� Date Rec'd
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CITY OF PRIOR LAKE PLUMBING PERMIT
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ES . Blue File PERMIT NO. j
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3 / 1
3. Yellow City
Applicant ((( /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/70 ` VA " at ,-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER .p An __ , /I-1 ^T
(Name) (Phone)
(Address)
APPLICANT �
(Name) .� GLs' f G i � S1/L,f I ,^,// (Phone) G.� /Z ,/t/ d e
(Address) 5 Z V r l- /TG-(' 'r /�(A/ PL
(Address) (Cit (Zip Code)
(Contact Person) ,QL (Phone)
APPLICANT SIGNATURE DATE 0, & - / 3
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
"SURCHARGE" has been extended $ Building Permit #
The minimum surcharge for a PLUMBING PERMIT FEE $
"fixed fee" permit is $5.00 STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ S 11-
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid J---y, s� Re i ( No. /' q
Date � - 6 - �3 By y
Building Official Date tS
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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