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��4PRI�� Date Rec'd
N , CITY OF PRIOR LAKE PLUMBING PERMIT ;ate
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1.Blue File PERMIT NO. 7
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3. Yellow Applicant /s-ai
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
\ O\ LOLIAAW Ort \Y
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER (�, 1 1( `
(Name) CA\\\ \I\US \V (Phone)"Iy `1Q
(Address) \\ L01/4_NANVN\CIS C YCk.k "(i)Y k.0\/APPLIC
1114\(Name) ANT 1 ``� 1 ` \AC' ' . ► Phone) `6)
(Address) i. - , ein �� ► v(,••
(Address) (City) (Zip Code)
(Contact Person) _ _ )O \CA (Phone)Cb 44b4144(fr
APPLICANT SIGNATURE _AL1 DATE q-A-cJ\J
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 i 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#
PLUMBING PERMIT FEE $ )��
STATE SURCHARGE $ $1.00
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid✓v 1 5z) Receipt No. 77 0
N Date By
Building Official Date ��
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372