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04 Y�0,� Date Rec'd
F CITY OF PRIOR LAKE PLUMBING PE T
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Blue Fik
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2.Gold oty PERMIT NO. /9-3 7D
3.Yellow Applicant
(Please type or print and sign at bottom)
• ADDRESS ZONING(office use) i
_,.Y31/ 6�1e-/O,t..WPOD S7 E -
LEGAL DESCRIPTION(office use only) ,
LOT BLOCK ADDITION Pu)
OWNER QJ
A/oRec„c , R0,/
(Name) /t�h'I �Ge. ,., 0 " i r. 4e) . (� 3_ , ,- -
(Address) 4/.7// f/z/ air (4✓p'j Jr JE, °t /vim Ltyir-
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APPLICANT Cr / - /H ‘L-Pic.
(Name) 7-72/ “/►)1 W1CYL 61gh, ‘L-Pic. . (Phone) Z20- rd7�`-7.2 q-
(Address) Jas" J'J/9vri'4v jig gly 6S- `-/(-4 ,i)1Jfi rj-3,17`
(Address) (City) (Zip Code)
• (Contact Person) $2.1.-7 ., C (Phone) 72P-Fr 7-..9.17.7
APPLICANT SIGNATURE (�
!!! DATE S'''f/ V
4 APPLICANT PLEASE COMPLETE BELOW -
s
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
" Floor Drain 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#
$5
PLUMBING PERMIT FEE $ (/9.S-0
STATE SURCHARGE $ S",iXi
TOTS PERMIT FEE $ Ste, ,�
} " (Offce Use Only)
This Application Becomes Your Building Permit When Approved ^Paid Receipt No.
Date ----/.
/'/ By
Buntline Official Date J � /0/ -- i.e.....,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372