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CITY OF PRIOR LAKE PLUMBING PERMIT /3 �5'
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PERMIT NO./s-
2.Gold City
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
L-L (e,O Ca La12_341, 'z' -e -`1. S E
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER q
(Name) S�� "� S k L��� (Phone) I I a' 1 L.- 14 a9
(Address) 4 160 7 ('r ) L Rig
APPLICANT
(Name) 2z77 Key, Q-—/ Lc�u nth (Phone) 9-S2 ABa
(Address) _ I %. _ . i
(A.dress) (City) (Zip Code)
(Contact Person) (Phone) 9tSa— —
APPLICANT SIGNATURE DATE 1:3-1-..S-c,LS
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 $
FATE SURCHARGE $ .50
"fixed fee" permit is$5.00 )TAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid Receipt No. 2
Building Official Date Date a• Cs.-- By
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372