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�f�'NESD�P Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 4 ,�
1. Blue File PERMIT NO .
2. Gold '7
3. Yellow City
Applicant Lr'
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
.:' c / Lf L ) .d" a t4 L011 F 5 '
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT
(Name) /Z. C p 1, ,, I p1r 4 ( (Phone) (, -) ' G._ — VSO " /11- `i
(Address) / q 7 Er C.' /� �L9 .' /t !' )9/.1 `"r' L/1'1 .5'.1 Z:
(Address) (City) (Zip Code)
(Contact Person) \, (/ 7 (• f/ c ,C (Phone) / — ( ./ . . , " .1 " 78 //
PLICANT SIGNATURE < - 4 . DATE 4 1"a / L.-
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
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ 444 .57)
STATE SURCHARGE $ - „r
TOTAL PERMIT FEE $ Z.
(Office Use Only) 1
ill
This Application Becomes Your Building Permit When Approved Paid �, - 5 .. Rece / No. /�
4/ Date ,, ] By 1 &,. 77
Buildine Official Date C 1 L-
i
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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