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o :� >� :; -'4,,-, ;� CITY Ol+ PRIOR LAKE PLUMBING P ERM 11 JUN 12 2009 [1
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v . e't• + ' CCg17
I. Blue File PE • i •
fNIV I SO 2. Gold City �'p ,'
3. Yellow Applicant
lease a or hint and sl:n at bottom ZONING (office use)
ADDRESS � Gt1+e ✓�'
I7 -5-7 s 9� & // (a 3 K /'l�
LEGAL DESCRIPTION (office use only)
PID
LOT BLOCK ADDITION
hone 2-' yy - 9L1 ��1
OWNER )a N rJ 0 r� S (Phone) S
(Name)
c 1 ► y A ) 55 - 7Z -- - - ---
(Address) /7/ Q l, I �� k4 c' S L ' r io i
APPLICANT 0 r Z - d
n Cal a to , C ft f (Phone) (Name) 5-4, � � J
2O - 64� S N , (7A vt
(Address) !
(Address) (Citi (Zip Code)
_
- a°� (Phone) '3 - S. -V 95
(Contact Person} � � � 1 - / � // ^ O �/
r ( /
APPLICANT SIGNATURE ,�_ _ _ ,,2 DATE 9
APPLICANT PLEASE COMPLETE ELOW T e of Fixture
T • e of Fixture MEM
Quanti r
— Routh-ins Bath Tub with or without shower Water Heater
Dishwasher Water Softener
Floor Drain Stand Pi .e Waslun_ Machine
Lavato Bathroom Sink Sewa.e E'ector
Launch Tra 1 or 2 com artment sink —■ Se va w Assembl
Shower Stall Backflow Assembl Test
Sinks 1 lirMill
Bar Sink __ Other
Water Closet Toilet
FEE SCHEDULE
Residential, New One &Two- Family $149.50
Industrial, Commercial &Multi - family 1% of job cost with a S49.50 minimum Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $ `V / c 50
STATE SURCHARGE $
TOTAL PERMIT FEE $ ____.' .
(Office Use Only) Erip No.
This Application Becomes Your Building Permit When Approved Paid ' Vt.)
iY
Date
Bulldine Official Date ,
24 hour 4646 Dakota Street S E Prior Lake, Minnesota9555 7274245