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CITY OF PRIOR LAKE PLUMING P IT
1. odic File PERMIT NO
2. Gold City �
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3. Yellow Applicant . V ~ �11
(Pled type or in t and sign at bottom) '.. , r�"
ADDRESS \ ZONING (office tae)
3S6 2 5 /tint/r )/. Sig/
LEGAL DESCRIPTION (office use onl}
LOT 1 BLOCK - 2 ADDITION /4 9'#i PID
(None} ..� L � °77, , 1 / (03 sL i
/ (Phone) Z
(Address) .� 62 yh h, (i- 5 .5
APPLICANT- ,--7 —
(Dame) .� arc I +v' y (Phone) C0/2 ".7b d
(Address)
(Address) (City) {Zi C)
(Contact Person) ' le ---1::/9 (Phone) _6/2 j , 5r ''v A
APPLICANT SIGNATURE t , DATE l / Z
d�
411 APPLICANT PLEASE COMPLETE BELOW
uan ' T e of Fixture uanti T ofFire,
Bath Tub w or without shower Rough -Ms -
Dishwasher Water Heater
Floor Drain Water Softener
_ _
Lavatory (Bathroom Sink) Stand Pipe (Wa;�hin IV)�ir
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly, Toot rX.
Bar Sink / Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Mufti- family 1% job cost with a $49.50 minimum Res New One & Two - Fam 8149.50
Res Add & A $4
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ 4iq.. _:
STATE SURCHARGE $ ,5 d D -51T
TOTAL PERMIT FEE $ SS SO O
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt N o.
i
Building officio Date Date fIz 4
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 z
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 4 :.
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