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Ot PRI0� Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT q.
d eiNN E se
1. s Blue File
PERMIT NO.`4-- z
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
2 r c ir 11-tofity (kidrA
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 'i (Phone)
(Address)
APPLICANT (?
(Name) f O�c J hU 4 (Phone) fQ /? d6 alK1'
(Address) )--y) 0 10./C 4re Ill, �'Ge�✓ 144 k
(Address) (City) (Zip Code)
(Contact Person) I �4>tvi� . - (Phone) 6
APPLICANT SIGNATURE ' ' • ` A_::_� _ DATE /
APPLICA PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain f 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 job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
Estimated Cost $ Building Permit #
PLUMBING PERMIT FEE $
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ Of. $7
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid [ S � Recei No. o 7,
Date By
v 6
Building Official Date "T a
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 L
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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