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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File PERMIT NO.
2.Gold City / IV
3.Yellow Applicant ✓
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/6.749na, i? 5Z-- 5537a /
LEGAL DESCRIPTION(o'e use only)
LOTL� ADD i,• ( PID AI OD 7•, 3
O(Name) Percy Fe/d (Phone) '9(5;7' Q d 7-000 '?
(Address) /674c )'hiv(a / r s''. - Pricy- i-a 5537
(Naame) I+/) iQV1 S (Phone) c 3— 4-45— -6 0 O r
(Address) I 0 5O Cha ( Blvd ( Q�
(Address) (Cit) (Zip Code)
(Contact Person) _ t II % .1 t (Phone)
APPLICANT SIGNATURE M 0 /.I / ! DATE 1
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
Residential,Additions&Alterations $49.50
Estimated Cost $ 606 , 00 Building Permit#
PLUMBING PERMIT FEE $ 54 0 0
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ c1-SO
(Office Use Only)
This Application Becomes Your Building Permit When Approved f!Pai co
ci
Receipt No.
Date / B
Buildine Official Date A y A _
24 hour notice for all inspections(952)447-9850,fax(952)447-4245 a
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372