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CITY OF PRIOR LAKE PLUMBING PERMIT L5!S
4rsocc.
I. Bole File PERMIT NO.
2. Gold city `5'� 6570
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS , ZONING(office use)
isZ3 nocrLc � C J
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name)
(Phone)
(Address)
APPLICANT
(Name) O i)c1 c. pivAA1 �.."Lc (Phone) G(Z — 77°- Cd.7
(Address) (le) '2 S-7 pito( r 7 Z
(Address) (City) (Zip Code)
(Contact Person) (Phone) 6(L _Z 7c'" 6.6-7
APPLICANT SIGNATURE DATE 6'/,.c/ls
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without showerRough-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
The Minnesota Statutes§326B.148 Building Permit#
"SURCHARGE"has been extended
The minimum surcharge for a UMBING PERMIT FEE $
ATE SURCHARGE $
"fixed fee"permit is$5.00 TAL PERMIT FEE $ L
This Application Becomes Your Building Permit When Approved Paid I Recei�f o.77
Building Official Date Date y is-yr By )1111111-
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372