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O i PR 0 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
44 /4/NEso°
Blue File
2. Gold City PERMIT NO. /3 . /46
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3e23 7 r
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name)
1J Tic � (Phone)
(Address)
APPLICANT r (11
(Name) ✓ � I r1- lit i (Phone)
(Address) b V Z & L j, NE(494T'Dpt- 6 -5 - v )d9
(Address) (City) � (Zip Code)
(Contact Person) t? 6 t e �j /
(Phone) �C ra)' _ u 4 a V 9r
APPLICANT SIGNATURE 'W DATE / — ?
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 1 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
The Minnesota Statutes § 326B.148 FEE SCHEDULE
"S11 1tGIIARGE" has been extended of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The minimum surcharge for a
"fixed fee" permit is $5.00 t $ Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ cc •—•
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid sl / Receipt No. ZD a ff
� f /
BuildinE Official Date Date 7 �j/, � 3 By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372