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PRI0 Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
rsoce
I.Blue City PERMIT NO. / 24-6
2.cola city
(Please type orprint and 3.Yellow Applicant
sign at bottom)
ADDRESS ZONING Iofrice use)
3S07 kivdkis N NAl
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
R<
(Name) V S Oh 'CZ -s2 (Phone) `1G O-- eo 0(4,71
(Address)3 SO 1 \')0n1 y\6\\5 r N \A/ T c ion( \O.\ l\P‘N ! 7-7),
APPLICANT, n
(Name) (XIV \ 9‘...Arn V 1 h (Phone) 5 13 G5 l 1-10
(Address) 3(170 C
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(Address) _ (City) (Zip Code)
(Contact Person) 1 'CO lJC (Phone)
APPLICANT SIGNATURE DATE 1 I 1 gJ2c
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 )10
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 1st $ Building Permit#
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ 4y
The minimum surcharge for a STATE SURCHARGE $ .06 -AB
"fixed fee" permit is$5.00 TOTAL PERMIT FEE $ L(. S 0
This Application Becomes Your Building Permit When Approved Paid t.�11, Sb R ipt No. U /'
Date,
Building Official Date , -11-
1 l y (/
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372