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(46PRI0,1
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
— a- 4
Blue File PERMIT NO.
2.Gold City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
1 46C 2)\6c —o —�� )\N O N ) ?PAU V-- . c-,) Pc)- 122-
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID 2C. 30' £3 ID
OWNER
(Name) CI\A--V\e‘ \
-GaVon C,,nYw\Soi ) (Phone) 0102-r l2i U A b 1.4 2 --
(Address)\A2)\k \1 ()D e. , Ab\N o �-a c. MN372—
APPLICANT
(Name) Lc f/y ' y-a''\-\-Y\ (Phone) 01`l�: Q 4° b\. A Z
(Address) 142-)\'6c V)‘c2-O b 1F-VY1 'p'J\\J GJ f \fid, l GJ 7
(Address) (City) (Zip Code)
(Contact Person) QA)V Y- � ' J AW\ (Phone) 61C71-- (p4& 6 \k2—
APPLICANT SIGNA • . '
DATE I �
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
Estimated Cost $ Building Permit# iinnesota Statutes§326B.148
5-1-) "SURCHARGE"
3261.148
SURCHARGE"has been extended
PLUMBING PERMIT FEE $ The minimum surcharge for a
STATE SURCHARGE $ 5- 'fixed fee' permit is$5.00
TOTAL PERMIT FEE $ 5-14
. Sro
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 5 SU Receipt No.,43 c ,
Building Official Date Date I (� 6"--- By cp"_L.
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372