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CITY OF PRIOR LAKE PLUMBING PERMIT l ✓tr'
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i.Blue PERMIT NO
Applicant
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3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
137 6 fthoit tc.S E.
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(NaV l e 1 v VLA) (Phone) 507_ pa " 0 0__
(Address) 1 "Y'3.-7 0 Ps1pO d J +- 2d ,
PPLIICANT TO n'S 14-.7c)((Q t Cei (Phone) qi-Da— "[ 3 s-a `T a
(Address) 'RC Q CO U0---Y '70( "l f V iil t v ( ,5337-7
(Address) City) q5';
� I`T r2 (Zip Code)
(Contact Person) PA ..41 _4 (Phone) — 3 6 'OZ 1(Ic
APPLICANT SIGNATURE DATE - m�
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
Q Residential,Additions&Alterations $49.50
Estimated Cost $ q Z R.66 6 Building Permit#
PLUMBING PERMIT FEE $ 9, 5�
STATE SURCHARGE
TOTAL PERMIT FEE $ 6 .50
(Office Use Only)
This Application Becomes Your Building Permit When ApprovedPaid % �p I ipt No. 5 3/
Bnildine Official Date Date i . ?A
, I ,
24 hour notice for an inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372