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CITY OF PRIOR LAKE PLUMBING PERMIT
e
' . B'"t F MIT NO
''` PERMIT
3 . Y eII city - ,,,9 S. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/4 a 31 Rs her 1 NW--
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER -403- I��
(Name)
OWNER-7-1_ Vl (Phone) *3
(Address) SaA f YNQJ ci o f LWNA 'Y %(\) , 5 3
(N PLIC A �� IOV'1 `.,''
(Name) LIED (Phone) 5` 0
(Address) al 0 U t w` 51
(Address) City) (Zip Code)
(Contact Person) I'> (I (Phone) (4\ '
APPLICANT SIGNATURE ' DATE I-2 fl -f;
.
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 ■f 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 $ Building Permit #
PLUMBING PERMIT FEE $ ■ 5 0
STATE SURCHARGE $
TOTAL PERMIT FEE $ 2 5O
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Building Official Date Date /27
'/ jg/�J By - L. - 7
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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