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04 .� Date Rec'd
N CITY OF PRIOR LAKE PLUMBING PERMIT
ti 7, 2q-4
I.is Gold City PERMIT NO. /cf 7 5/
(Please type or print and sign at bottom) 3.Yellow Applicant
ADDRESS ZONING(office use)
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LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID l i 3i,ob ; Uli0
OWNER ,a47j�5Z
(Name) Lam) C-- l 4 (Phone) 1Q 5 511 "7
1
(Address) I'-/Z2 1 L) '- 0:71.i} N
APPLICANTy,A
(Name) S�-/ V i (Phone)
(Address)
(Address) (City) (Zip Code)
(Contact Person) (Phone) J
APPLICANT SIGNATURE ___64,4:e ,� DATE 5;1 ) 7- Z®J
APPLICANT PLEASE COMPLETE BELOW ✓
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 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
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# 1 ne lvlrnnesora marures s 3L00.1,1.0
"SURCHARGE"has been extended
PLUMBING PERMIT FEE $ q94C) The minimum surcharge for a
STATE SURCHARGE $ S '0). "fixed fee"permit is$5.00
TOTAL PERMIT FEE $ 54,513
(Office Use Only)
mL., TS:..._ .,, C4-........4-.-..-..... .... C4-........4-.-..-. £ ) D 1 AO
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This Application Becomes Your Building Permit When Approved aid z`3 -/,; /. Receipt No✓ e
Buildine Official Date ,4late 55i#3.2)
L f By 51A-Lir _
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372