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Niet:DRI-644 ,_ CITY OF PRIOR LAKE PLUMBING PERMIT J� 21^
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I.Blue File
2.GoldAiry PERMIT NO. I .J L--"
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3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
I LI I tC LL5l t ( i 1Pq4 c N w -Pc`i 11 c c.. a le * Y i\') s—s—17(9- 4 3
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID 4\ 'btl:`j'
OWNER
(Name) O ,,c TQ ( W C 0 v\\ (Phone)9 ') D-' 14 q Co 0 li/3
(Address)
APPLICANT
(Name) �4 y a n GP— PI G nA tor n 8 IN c. (Phone) q S g- 3 "74' 9 Co I (
(Address) d- 1 b)( 1.4 t 69 q. PIN) ren Q t i-In 5 = L-f t___
(Address) (City) (Zip Code)
(Contact Person) C. ( It. ,.9 01 1,,, (Phone)
APPLICANT SIGNATURE DATE —5.----0—/ — [/
5----
APPLICANT
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 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
SinksBackflow 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
BuildingPermit# tot= inattis oLa acacttc.c.) ;3 `""" i-1"
Estimated Cost $ "SURCHARGE"has beer.extended
PLUMBING PERMIT FEE $ SI2The minimum surcharge for a
STATE SURCHARGE $ S "fixed fee" permit is$5.00
TOTAL PERMIT FEE $ RI,
(Office Use Only) Th,, A/IinnaLnt-) Ct7tlitac R 27F111dR
This Application Becomes Your Building Permit When Approved Paid .54.4 GO Receipt No. 14 L i
Date t- 2A i c By < pt
Building Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372