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OQ PRIp� Date Ree'd
CITY OF PRIOR LAKE PLUMBING PERMIT
E. 79. t
ar se. 1.alae File
s.aold rtY PERMIT NO.1 `
B
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS t l•I CIS� e ` \ �� ZONING(office use)
. 1 N �P
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID0214' 0'
OWNER I✓ OA,l t f �zl of (igg g 1 11 I i
(Name) -/ - W 1 (Pihone)
(Address) �nb'1 ll c 1. Pr l
APPLICANT \ (Phone) 914S— 914 nru.S U Ituyv,hv \AST
n _ � wv c
(Address) to- 314 �l/�'� U�� (. -c., SSI ) I _
(Address) Pt
(City) �1 , ((Zip Code)
.(Contact Person) ,i, IcJ / (�(Phone) ` ('7 I 9141--/
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher l Water Heater
Floor Drain Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(I or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet(Toilet) Other
_ FEE SCHEDULE
The Minnesota Statutes§326i3.1145 job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
"SURCHARGE"has been extended Residential,Additions&Alterations $49.50
The minimum surcharge for a
"fixed fee"permit is$5,OQ Building Permit#
PLUMBING PERMIT FEE $ c? .w
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $ S S v
(Office Use Only) •
This Application Becomes Your Building Permit When Approved Paid Receipt No..-7 f /
Date/� 2. 1 /4, '
By _ c
Building Official Date 1' �"�'
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.C.,Prior Lake,Minnesota 55372