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4 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
1.YelBlue File PERMIT NO.j 7/ 9 pp 3.Yelll ow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
164441 AI k Ltd 'lb ) 6-E_. �(
LEGAL DESCRIPTION(office use only) �,�-
LOT BLOCK ADDITION P]D OW ' 023. 1-65-
OWNER
b OWNER
(Name) 114()A4 A S 1 M W ivl (Phone) 4I S i- 44-7-3z>2
S
(Address) 4-eq )]2,gl+1+AL1 TEA 1 L SE. rat a,'L. L lL.�. MN/ 5 5 3 -7,- -
APPLICANT-,,
(Name) 1 -lG`/ 1�,.; �4.c.-1% (Phone) 76> �.?f ?f7.2,
(Address) 16 3 0 3 LU N
(Address) (City) (Zip Code)
(Contact Person) \r'r (Phone) k/5-
APPLICANT SIGNATURES DATE
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 V 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 tie ivilunesota elutes S 3L00.1`Y0
PLUMBING PERMIT FEE $ "SURCHARGE"has been extended
STATE SURCHARGE $ The minimum surcharge for a
TOTAL PERMIT FEE $ "fixed fee"permit is$5.00
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid SLI S,--b tcecelpt No.� /q j,
C T
Building Official Date Date gt_f_ By 3)".4.), , ,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372