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CITY OF PRIOR LAKE PLUMBING PERMIT tivDate Recd
4r so
1.:led 'Ile I PERMIT NO. `' -
2.Yell /47 --)it3. �� G�J/)
ADDRESS
4 G SSP 1-ek o,I - Ss- -S ZONING(office >
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION
PID
OWNER k ^ ' ,
1-6
(Name) ��1 �vY,f'-`I� -7
4 S (Phone) �� �.. / S — 7
(Address) (P� LS G Y � Si-- 5 E p 1( 0 f
A.PPLICAN4 a \
(Name) d Cst..M • a 1 Ur`VJin (Phone) G 12---)__6s—to 0(Q 6
1
(Address) '�j -7 CT I TO net v ) I L 3
(City) (Zip Code)
(Contact Person) 1 (}- '-')q
Q �'� (Phone) �I Z� G G 1 �-c)0 Z.
APPLICANT SIGNATURE f /� ,� `�� DATE3 / Z 3 I)3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture
Bath Tub with or without shower QuantityType of Fixture
Dishwasher Rou_h-ins
Floor Drain 11111111.111111Water Heater
Lavatory(Bathroom Sink) Water Softener
Laundry Tray(1 or 2 compartment sink Stand Pipe(Washing Machine)
Shower Stall Sewage Ejector
Sinks Backflow Assembly
Bar Sink Backflow Assembly Test
Water Closet(Toilet) Lawn Sprinkler
Other
FEE Industrial,Commercial&Multi-family 1%of job cost with $49.50 minimum
Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended it $ Building Permit#
The minimum surcharge for a
"fixed fee"permit is$5.00 PLUMBING PERMIT FEE $ ,. v
STATE SURCHARGE $ 5-, ode
(Office Use Only) TOTAL PERMIT FEE $ 5-4 i,3-00
This Application Becomes Your Building Permit When Approved Paid
�di64tt//
,g) ipt No.s 7
Buildine Official DateDate-3 ,- -� 1
I(,.
24 hour notice for alt inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372