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N , + CITY OF PRIOR LAKE PLUMBING PERMIT (o
I. sold File PERMIT NO /3 1/(
2. Gold City
1 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
yV / Qo e� ' S -1
LEGAL DESCRIPTION D DESCRIPTION (office use only)
LOT d v BLOCK 2 ADDITION t,(J i P la►CS 0/G/- / A/ CA PM � -5 06`0
OWNER
(Name) ^. (Phone)
(Address)
t'
APPLICANT n // /
(Name)_._ l V " / � 6 (Phone) v /- C� ' ) ‘7- C�
(Address) L h A - AAU1/ A 5Sir U
Ad ess) (City) (Zip Code)
(Contact Person) (Phone) v / C63 (`.7o
APPLICANT SIGNATURE Z --- f ! i' ' DATE A) :2/-
APPLICANT PLEASE COMPLETE BELOW
• uantity Type of Fixture Quantity Type of Fixture
n 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
Industrial, Commercial & Multi - family 1% of lob cost with a $49.50 minimum Residential, New One & Two - Family $149.50
The Minnesota Statutes § 326B.148 Residential, Additions & Alterations $49.50
"SURCHARGE has been extended Building Permit #
The minimum surcharge for a
"fixed fee" permit is $5.00 ,UMBING PERMIT FEE $ . 5.
'ATE SURCHARGE $ t
TOTAL PERMIT FEE $ .S . 5 d
(Offic . + .1
Thi t 1rcation Becomes Your Building Permit When Approved Paid r Receipt No. i
3 l7 9 j Date 5 t By 1
Building Official 4 Date ! lJ Y
—
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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