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04 p�0� Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT Z� f
sole File
2.cold city PERMIT NO.
3.Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
9 Fii,t_ten--awks ijvt. z 5:6
LEGAL DESCRIPTION ffice use only)
LOTLOCK AD ION PID 43%7524459-"0/4 f":"
OWNER .—
(Name) /. I ! . 1 (Phone) q b O 3/023
(Address) sot rn.L.'
APPLICANT
(Name) (Phone)
App lance tbnnections tnc.
(Address) 14850 Chestnut Blvd.
(City) (Zip Code)
-445-48
(Contact Person ., • , __ (Phone)
APPLICANT SIGNATURE IA..a. t;. _ DATE
S/0/61
'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 $ Building Permit#
PLUMBING PERMIT FEE $ i)���
STATE SURCHARGE $ 5�lJ
TOTAL PERMIT FEE $
(Office Use Only)
i
This Application Becomes Your Building Permit When Approved f Receipt No. �/
l 50
ate By "(
Buildinc Official Date 1"(I/it < ( 1k
24 hour notice for all inspections(952)447-9850,fax(952) `447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372