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4 P114 Date Rec'd
�' C OF PRIOR LAKE PLUMBING PERMIT /& f] v
4 r so*
I. Blue File PERMIT NO 9(/' 7
2. cola city
3. Yellow Applicant
lead ol,print and sign at bottom)
ADDRESS 7! ZONING (office use)
,/
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) , D 1 (Phone)
(Address)
F LWANT y
e • h Ad ._ L .0 (Pho -
Address) ' �L 2- k I . 4 ; i 1- 4 ', ...ail- , . -17, 4
/ (Address) (City) ' (Zip Code)
•. ntact Person , I a . / d SP (Phone) / �-_) -ci - d' l � e - V 9Y
• ' • ICANT SIGNATU • 1 :' , it ATE 9 / 2 /
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 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 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 # rej
"SURCHARGE" has been extended
The minimum surcharge for a 'LUMBING PERMIT FEE $
"fixed fee" permit is $5,00 ;TATE SURCHARGE $ .50
COTAL PERMIT FEE $- 0
This Application Becomes Your Building Permit When Approved Paid S / S --0 Rec • t No. - v j 2. ___
Buildine Official Date Date 24 By .
24 hour notice for all inspections (952) 447 -9850, fax (952 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372