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04 PRIO,� Date Rec'd
1 1 CITY OF PRIOR LAKE PLUMBING PERMIT 4
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Blue File
.Gold 'Aye PERMIT NO. /5 e9/,./s4
type or print and sign at bottom) 3.Yellow ApplicantI
ADDRESS ZONING(office use)
C°1 -7 `-rG,,,,.o1_ D4 _ ?Usk
LEGAL DESCRIPTION(office use only)
ALOT LOCK / ADDITION A4Cig,i..ifD ) D — 5701
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OWNER
(Name) (� r) (Phone)
(Address)
PPLICANT Q c��/2 c�/��U �j ,/
(Name) 4� l'(� !� ,,��/ (Phone) ��� ��0�'cl ��S
(Address) , Z vi frtki-rG6� ,N' 6,7&( /'yl s37/e)d
(Address) (City) (Zip Code)
(Contact Person) g st/",( (Phone) 642-- 170 1 IVq/
APPLICANT SIGNATURE tet'(i11a2y DATE S`/S`/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 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
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 $ 2-00.. Building Permit#
The Minnesota Statutes§326B.148
PLUMBING PERMIT FEE $ 1-L/' 'SURCHARGE"has been Extended
STATE SURCHARGE $ 5 The minimum surcharge for a
TOTAL PERMIT FEE $ c.a "fixed fee permit is$!x.00
(office Use Only)
This Application Becomes Your Building Permit When Approved r ! � Receipt No. 1. 1
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Building Official Date
IIIMIlli
yII
24 hour notice for all inspections(952)447-9850,fax(9MI
5)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372 AO