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Date Rec''d
oi pR104A. CITY OF PRIOR LAKE PLUMBING PERMIT gi 3, 14''
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44141
pgSe 1.tui
F t PERMIT NO j
2. ll city
3.Yellow Applicant
ease j, or . t and s' , at bottom ZONING(office use)
ADDRESS
G IS Iii. ks.ktli Pok .
LEGAL DESCRIPTION(office use only)
PID
LOT BLOCK ADDITION ]
OWNER (Phone) —
(Name)
(Address)
a - T ( e.', 1 (Phone ctc2- j f®- 3`477
(Name) _
(Address) (City) (Zip Code)
(Address)
(Phone) _____
1
(Contact Person) _��
DATE
APPLICANT SIGNATURE A'
APPLICANT PLEASE COMPLETE BELOW T e of Fixture
Iuanti T At a of Fixture I uanti
—��
Bath Tub with or without shower Rou 1 h-ins Water Heater
Dishwasher Water Softener
Floor Drain Stand Pi e e ashin: Machine
La :ath Sink Sewa:e E•ector
Lauurara I Tra 1 oI or r 2 com•artmerat sink Backflow Assembl
Shower Stall �. I Backflow Assembl Test
Sinks i`►� Lawn S arinkler
Bar Sink �- Other -
Water Closet Toilet
FEE SCHEDULE
Residential,New One&Two-Family $149.50
Industrial,Commercial&Multi family 1%of job cost with a$49.50 minimum Residential,Additions&Alterations $49.50
Estimated Cost $ Building Permit# The Minnesota Statutes§326B.148
"SURCHARGE"has been extended
PLUMBING PERMIT FEE $
`-/4- re} The minimum surcharge for a
STATE SURCHARGE $ "fixed fee" permit is: 5.00
TOTAL PERMIT FEE $_
(Office Use Only) Paid 5� S� R ipt Nam�G 2 6This Application Becomes Your Building Permit When Approved l _l
Date(/
O (>„ ( 1111F
Building Official Date f
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372