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6.— Date Rec'd
„-:e CITY OF PRIOR LAKE PLUMBING PERMIT
4. 'ite:,
I NNES� 1. Blue File
2. cold City PERMIT NO. / Z + 3 77
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3 On Ownhedi'Grf 5 Trot' , Priors ice ow SS 37
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Nam OWNER �01 61 e l I m ar (Phone) q5 a -RV V- 773 1
(Address) 300 ( N2 tq v I ` 17 1 1
APPLICANT J (15a - �f 35 -a 1 -1 1 4
(Name) Vrly `S �1(Gnc '' (Phone)
(Address) �o q 0 CouirrAi T.0� IA 9-a a l3l� rni Vi 1 f , ?71kJ S(-): (
(Address) (City) (Zip Code)
/_ G
(Contact Person) _ ' A g !. (Phone) Q.S �
- 5 J _ 'I d "I eR
APPLICANT SIGNATURE 1 I /I. / DATE 961'
i
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 $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $
(Office Use Only)
I
This Application Becomes Your Building Permit When Approved Paid 1 /9. JO Rec ' t Notr? y S 7
-
Date By J `/
Buildine Official Date S .- . I L
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372