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CITY OF PRIOR LAKE PLUMBING PERMIT
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°�� 1. Blue File . cola city P ERMIT NO. 13
3.
. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Loa 5,g Fran
LEGAL DESCRIPTION (office use only) �j ,L� 9J
LOT 4BLOCK ADDITION I 949 944" & PID e5 -457- pill p
OWNER
(Name) M .1 oiflQ G t,S rmari (Phone) -4-417-61 7/
(Address) (€ �j o1 1�' rG ►1 !�( r e- i 5F.
APPLICANT
(Name) (Phone)
(Address) Comedians Inc.
'' tit Blvd.
(A ` , , $N 55379 (City) (Zip Code)
;IK
(Contact Person) (Phone)
APPLICANT SIGNATURE / t t Al % , DATE /0/
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
The Minnesota Statutes § 326B.148 FEE SCHEDULE
"SURCHARGE" has been extended pf 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 $ ,344 a o
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ S so
(Office Use Only)
This Application Becomes Your Building Permit When Approved
5 �(. `s O Receipt No. r7
ID. q. 0 ate " "�� By [[ G�
Building official Date ID - q , J
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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