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NCITY OF PRIOR LAKE PLUMBING PERMIT i' sor
I.BlueFi1e PERMIT NO
2.GoldCity NO./4—
W
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
3 -ii /I s '
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PH)
OWNER /�
(Name) Ve ra d. ew ck,' (Phone) l—7/3-'3C6—d o98
(Address)
APPLICANT ��� /1/1/4,144"-4-
�A
(Name) ...;i!ji' /v//41 4"-4. PO -6 (Phone)
(Address) /71v 31-2- w. Sh4 rel ,✓ 5 f339
/(Address) (City) (Zip Code)
(Contact Person) �C ��1lh.-(I (Phone)
APPLICANT SIGNATUREe,'( DATE 67' 7�
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
The Minnesota Statutes§326B.148 Building Permit#
"SURCHARGE"has been extended
The minimum surcharge for a UMBING PERMIT FEE $
"fixed fee"permit is$5.00 ATE SURCHARGE $ SI,p3--"
ITAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid5/5i Receipt No. /76 s
Date B
Buildine Official Date W_ `C' -
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372