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. PRIG Date Rec'd
e CITY OF PRIOR LAKE PLUMBING PERMIT
Yk 32 /f/V—Ci
•NW I. Blue File
2.Gold city PERMIT NO. 4. /
3.Yellow Applicant f
(Please type or_print and sign at bottom)
ADDRESS ZONING(office use)
l a-S 6'4 Y.- „col. t;,,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER �C
(Name) / �'- (Phone) g'— if l _9<`
(Address) L/3O/ ffJ t'S ll7,/ ffr"it%�L,vJ� �% ,S'�37
APPLICANT
(Name) _ / dl`. ..l_' (Phone)
(Address)
(Address) (City) (Zip Code)
II
(Contact Person) Lcc-- 1Cl�f�C�K am/ (Phone) <q -(,_q
APPLICANT SIGNATURE ..2 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 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
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended $ '7 7" . Building Permit#
The minimum surcharge for a PLUMBING PERMIT FEE $
"fixed fee"permit is$5.00 STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ �'�f e S"0'
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5- R ipt No. •3 4
7 ._
Date I,L J i ti. B [�
Building Official Date '
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
1