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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 6 , /3'. /4 I Blue FApilep PERMIT NO. l 52_, /
2 Yel
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
04 /�ti --7- rrcaelfr`L mc,, / Ei X23
� aL�f YL'Ga�c v�
LEGAL DESCII;IPTION(office use only) - ,/ j > �i
L�,.9-L. 6 yob s✓, tie /,16s ad) PID 075- l S o -I
LOT BLOCK ADDITION
((NaWNER) CC CciE,t,t- C J/I- (Phone) c?4j 2. - Lr C a.- ge ) --
(Address) 2? .7 7 - Soec7' k // Li',Ai ect �/
4
APPLICANT n ! n/ `/ j - �j G, L
(Name) f. `i butt-) t l'C �i. ,..(0 [v t�r. �"t r*weir-J._" (Phone) 9"5. — T�7 l / 6%
(Address) (`5`7oc% /�Z,e /crick c.` r�;,• iv-e /�% - /2/a ti-t r 5e; ®l l
(AddrKss) (City) (Zip Code)i
(Contact Person)
6✓-- cA. (Phone) CI 2.. 7 S1- � �J
' 4/
APPLICANT SIGNATURE - DATE , i
Q * APPLICANT PLEASE COMPLETE BELOW ME-Ch • Aoov1-+ - C)
�F
Quantity Type of Fixture Quantity Type of Fixture Sii E
Bath Tub with or without shower Rough-ins
Dishwasher .3 Water Heater `)jWZ
/,
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 job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
52/' - 00 Residential,Additions&Alterations $49.50
Estimated Cost $ Building Permit# The Minnesota Statutes .32b15.145
"SURCHARGE"has been extended
PLUMBING PERMIT FEE $ The minimum surcharge for a
STATE SURCHARGE $ "fixed fee" permit is$5.00
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved r Receipt No.
f "J i f 2s
ate ( _ s\� , By c
Building Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372