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0�PR10 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
2,2, IS-
v
I.Blue File PERMIT NO / 7)>'
z.cow City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZO I G(office use)
i? V Cide -glisiN. �=
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(Naamme))R 4/A06 (Phone)
(Address) n w 42g.
APPLICANT-1->d ,/p, z �la�"�,•, (Phone) &1614-1,--Z/ ' 9-
(Address) apa 41 /1 /47-4d�
(Address) (City) (Zip Code)
(Contact Person) ltfi (Phone)
APPLICANT SIGNATURE ' DATE .0)
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 t 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# 3L.a.GUUea g JGUD.J ro
d1 fe-ARGtr" Fi;_}s been extended
PLUMBING PERMIT FEE $ r:tie minimum surcharge for a
STATE SURCHARGE $ • ,,fixed fee' permit is$5.00
TOTAL PERMIT FEE $ , /f6'
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paidl L Rey t No. 62r1_„,..
Date2
Buildine Official Date •
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372