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C CITY OF PRIOR LAKE PLUMBING PERMIT
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2, Bold d City
PERMIT NO. 1'721 C — 1
(Please type or print and sign at bottom) Z R 3. Yellow Apprau
`� 1 2' O 1 A'+ I D J � Q j ^ \A) ZONING (Deice sue)
LEGAL DESCRIPTION (office use only) J
LOT BLOCK/ ADDTITON PM 25. 3/ (e. Ocf- 0
� R DDaiul ki)a,i I xX 1 (Phone) 15 ! (f.
(Address) SA- 0
(Name) LAl(IPA s \OK1 V\V,9\AQ'(�� _ (Phone) r m�
(Address) �` 1 , a m (1.1(� � 0 v ��� .3
( (, (� (Address) (City) (Zip Code)
(Contact Person) N f (Phone)
APPLICANT SIGNATURE DATE I 0 4 31 P 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
1 Water Closet (Toilet) Other 1
FEE SCHEDULE
Industrial, Commercial & Multi - family 1% of job cost with a S49.50 minimum Residential, New One & Two- Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 $ Building Permit #
"SURCHARGE" has been extended
-
The minimum surcharge for a 'LUMBING PERMIT FEE $
"fixed fee" permit is $ 5.00
■TATE SURCHARGE $ 0 g: 9–
■
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'OTAL PERMIT FEE $ LJ _ 0
This Applica omen Your Building Permit When Approved Paid 544 .SZ Receipt No. 6 Q,to 1
Bail Date Date
117/111011111
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 (� p/�
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 yl-- _!`'V`J