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04 P R10 4 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Gold Blue File 45 _ , 3e/
2. ,� Coy PERMIT NO.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS �` ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N L \ *\ �t (Phone))3 a 3q 3 3DDD
(Address) (3LQ e7k C \ 1!i-
APPLICANT
(Name) N7 0 ef),Dtl x,t (Phone)
7) ) `mil b `k L arN l.tD ` 5"4. 0 l Lp
(Ad r ss) j (City) (Zip Code)
(Contact Person) '..A _ (Phone) b ��
APPLICANT SIGNATURE DATE 1 (-1
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 of joh cost with a $49 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 $ 1 4 5 U
STATE SURCHARGE $ �S
TOTAL PERMIT FEE $ __5
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid J Receipt No. A po
/ 1/3 By
Building Date / 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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