HomeMy WebLinkAboutPlumbing Permit 13. 1052 1
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0 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File PERMIT NO .
2. Gold City ` �, _ J /1
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3. Yellow Applicant !U /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 s3 f 1 a2C Cr,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 11
(Name) P R ) 7t (Phone)
(Address)
APPLICANT (' / �//
(Name) 4 ' 0 b .1-\� t h (Phone) (// r -} - f 2 d 'j l 9S
(Address) rZ Y2- lX rn,f, 4 444 6/, Alb! r s y ?!
(Address) / ( / Zip Code)
(Contact Person) e(? L ,r-a t/ / City) -( 21'6( (Phone) 6 ? )-- �a 0 ( 7 �.�
APPLICANT SIGNATURE v t 7' DATE 7 - y'
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
The Minnesota Statutes § 326B.148 of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
"SURCHARGE" has been extended Residential, Additions & Alterations $49.50
The minimum surcharge for a
st $ Building Permit #
"fixed fee" permit is $5.00
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ -/- S(
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid j---/ 5 . 0 Receipt No. 0Z3
Date 9/' 7 /Y3 By/--- ,�,. -C�
Buildins Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372