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O� p0� Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File PERMIT NO
2. Gold City . / p 2 ��
3. Yellow Applicant �,.J
(Please type or print and sign at bottom)
ADDRESS _ ZONING (office use)
I �Fain nT 1 SE-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID k s
((Name) Y 1 3rtv. �/i, (Phone) ( ) \ �O7 5 c) ? -o
(Address) � ,'!(" Tr , Lc -, VY)' D.
APPLIC
(Name) r t [ � /� k (Phone) V ° 1 Q
y 1 �
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(Address) " .. 1 .4' I. PA , %L��l N 1 23
t ( (City) (Zip Code)
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(Contact Person) 1 ( 5 (Phone) t \ kj5 1 :
APPLICANT SIGNATURE DATE — . 1 9 (3
APPLICA T 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 l% 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 $ -' 1
STATE SURCHARGE $ - ' .5$
TOTAL PERMIT FEE $ '
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid $ 5 Receipt No. y , 7
Date a /,� By
Bulidine Official Date //�3 L
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 `.,,
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 ,¢l�d9