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*II R10 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT L L . /3
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�1j�,NESOce� 1. Blue File ! PERMIT NO . d Ve 2. Geld City 3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
� L11O0 � ...rr�.- (r
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT - /Z��C� � L C '2 (
(Name) /� p � ' (Phone) °'1 5.� q �' 7 ' S 6
(Address) 4 0 a I ; l j 1 t^ o r L.-1A 31 )-
(Address) (City) (Zip Code)
(Contact Person) C CV-
(Phone) (e, 1 2- Li 8 3 - a.
APPLICANT SIGNATURE DATE ZZ " /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
"fixed fee" permit is $5.00 'LUMBING PERMIT FEE $
;TATE SURCHARGE $ r ciR)0
TOTAL PERMIT FEE $ i s
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Rec ip No. 6�
Date �1 7 By
3
Building Official Date P Z' 1 . t
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372