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8 Cm CITY OF PRIOR LAKE PLUMBING PERMIT czt
7.3 Blue File PERMIT NO. /�_ia�9
2. Gold City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS p ,�9 ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) 7) l? t h. (Phone)
(Address)
APPLICANT D „ /� ) ^ G /
� -�J �rG *Q r
(Name) - �LUl C (Phone) &/..), " CI b F 1 � `715"
(Address) 55 L y Z at,akk.4 -0e. 4/. 44.1./ .42
(Address) (City) p (Zip Code)
(Contact Person) eS' �� (Phone) ( Oa - C 6f "4/4.5
APPLICANT SIGNATURE R 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
"SURCHARGE" has been extended of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
The minimum surcharge for a Residential, Additions & Alterations $49.50
"fixed tee" permit is $5.00 ,t $ Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ ; „CV. 5
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt 7/ d og?
a g?
Building Official Date Date V .2_ 4 3 By L i
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372