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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT / Z?.i�'
4r o0
I. Bine File PERMIT NO/ OG2
2.Gold City
(Please type or print and sign3.Yellow Applicant
at bottom)
ADDRESS ((Q `J1(\ ami G f e e k C S� ZONING(office use)
�
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER p 1 1
(Name) 1010.4-'" 5 e-►1 e�y�,.e.'�h O''Y\ G 5 a 5 a 1 1 a3
(Phone)
(Address) \ (2gd �e C fet' CI- gr.
APPLICANT I
(Name) 1-No•w ) (Phone) (06( 365 134 o
(Address) 3(9/0 DO dU R C) cc/ o3
(Address) (City) (Zip Code)
(Contact Person) 11 0 , G-10 (Phone)
APPLICANT SIGNATURE — DATE J / X71
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# 'tue Minnesota statutes g 3Gbti,1'U
PLUMBING PERMIT FEE $ �y Co "SURCHARGE"has been extended
The minimum surcharge for a
STATE SURCHARGE $ S. o
TOTAL PERMIT FEE $ 6--q. go
"fixed fee"icerm ts5.�0
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid...9/.5v Receipt No. t?r
r .JJ
Buildine Official Date Datel 1 !� 13 •
24 hour notice for all inspections(952)447-9850,fax(952)447-4245`
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372