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O�CCITY OF PRIOR LAKE PLUMBING PERMIT
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1.Blue File
2.Yell APERMIT NO. (
City
3.Yellow Applicant J ] .
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
S L 30 mq,o. P SE
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER i, S+o- (Phone) (DP SG(- c6 c0 q 7ame
(Address) 1-V12(:) M as or li2, se, ?Ae \ 4,4_ f IV1 N g S3 2 2
APPLICA4T �` � ��j) 31v� I 3 �
(Name) CA\.o w.p l t �'"� v•,3 (Phone) �
(Address) 3(01 ) 10 o chi V)N. SO.r...‘Uv\ IAN Cc) 2.3
(Address) City) (Zip Code)
(Contact Person) r oy Go� (Phone)
APPLICANT SIGNATURE DATE 1 I ZOO 1,01 LI'
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 1 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 ,n
Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,New One&Two-Family $149.50 Tw
Residential,Additions&Alterations $49.50
1st $ Sl Building Permit#
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ 4a► .SO
The minimum surcharge for a STATE SURCHARGE $ r,,.0 0 ,A
"fixed fee"permit is$5.00 TOTAL PERMIT FEE $ g t/.g O �
This Application Becomes Your Building Permit When Approved Paid 5 ' lir eipt No.
Dat (- IIIL
Buildins Official Date 41$ L
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
11
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372