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Qi PRI0_ Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT Z�, �S
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2.GoldPERMIT NO. •G� (J/J �/
3. YellowCity S(�X
Applicant �/
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
33O0 4nX Q Tr l 553-7a
LEGAL DESCRIPTION(office use only) , / �-- `��1/�
LO1 BLOCK 3 ADDITION S 1../41../45e � /G�S �f /lJ PIDO�,/' o$ LO
(NaamNER jill)nO(C24 ' (Phone) 651-30g- 031;•
(Address)5300 c5prveQ, Yr I Tri Lake 5537
APPLICANT 9 r tInn., �`ZecfL LO (Phone) ?5a 445 448613(Address) d 5O ckQjh [ a VC( LSka kops 653-19
(Address) (City) (Zip Code)
(Contact Person) S IA a / t.,I J (Phone)
APPLICANT SIGNATURE I! i.III! .. I I DATE a3 ?-Q
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher f 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 ~est $ Building Permit#
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ 99''
The minimum surcharge for a STATE SURCHARGE $ _, aV
"fixed fee"permit is$s5 O off TOTAL PERMIT FEE $ _
• S77 '(/
This Application Becomes Your Building Permit When Approved 1140,d Receipt No. 1
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Dater, 2 7. J---*"-By
Building Official Date5---
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372