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O� PRlp� Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
"r'ESOo I. Blue File PERMIT NO .
2. Gold City I 3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER / / y L� �
(Name) D /Qf �L�i�l �2f/ I'l, (Phone) (f ( 7 U' 3 9f
(Address)
APPLICANT l j D,
(Name) / (2) 1 . . - (Phone)
(Address) S y2 C2/4 be- 4 re Ai. X& /d
h S3 V,21
(Address) (City) �y (Zip Code)
(Contact Person) Rd)) �/.4 (Phone) lli /c)-
APPLICANT SIGNATURE £ DATE 1 ( — / 7 /3
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 C 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 $ _2-o(/ Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ j 7 . ,5
(Office Use Only)
This Application omes Your Building Permit When Approved Paid] Z ec pt No. /i . / •
� j `? , Da 7J ls? C
Building O dial Date n
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372