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410 Date Rec'd
a CITY OF PRIOR LAKE PLUMBING PERMIT /a_ -2,r1 IJ
47.soo 1. Blue File
2. Gold City PERMIT NO./3 / % Z 6 2_,
3. Yellow Applicant 11
(Please type or print and sign at bottom)
ADDRESS d G, ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION A e "may' PID
OWNER
(Name) (Phone)
(Address)
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( a 7 2 62 U � 1,4x, mw. � 4 v2- —
(Address) (City) (Zip Code)
' j
ntact Person / .:__,2 i (Phone)
' ICANT SIGNATU' Li" u l % %.1 1 _ _ DAT . O )",, L
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 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 Building Permit #
"fixed fee" permit is $5.00
LUMBING PERMIT FEE $
STATE SURCHARGE $ IVY
TOTAL PERMIT FEE $ AM 0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Rec ' t No. - 0 33 -7
Date `0 M 11t1 • 6 ' (� B y
anticline Official Date "
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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