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CITY OF PRIOR LAKE PLUMBING PERMIT •.
Lse,t. .. .. aloe ene
aura caY PERMIT NO. /5-- 2,0 5 I
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/1-(33-3 Sliote. e k esT DovE ,v c,J
LEGAL DESCRIPTION(office use only) •
LOT BLOCK ADDITION PID
(Name)ER (,(Jen1.5/`4Aa`i I—CO/Lee-7S (Phone) _
(Address)
APPLICANT0
(Name) (L , / bQ S. I (Phone) `�0
(Address) e( d( C-eNT2.trf( /4v s' Rita L M. RilI Y-l." 5:6-41,1
(Address) (City) (Zip Code)
(Contact Person) 't C `� k� (Phone) 710? seS---/ X 00
APPLICANT SIGNATURE , ■.•_.,.r DATE 5 /
`
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 l 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
The Minnesota Statutes§326B.148 f job cost with a$49.50 minimum Residential,New One&Two-Family $149.50
"SURCHARGE"has been extended Residential,Additions&Alterations $49.50
The mi►3imuin surcharge fol a �-{�'�
• $ Building Permit#
"fixed fee"permit is$5,00
.PLUMBING PERMIT FEE $
STATE SURCHARGE $ XXX 5.00
TOTAL PERMIT FEE $ S14150
(Office Use Only) •
This Application Becomes Your Building Permit When Approved Paid 51_, R ipt No.-_
"I
•
Bulldine Official Date Date _111 . S
24 hour notice for all inspections(952)447-9850,fax(952)14147-4245
•
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
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