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-C CITY OF PRIOR LAKE PLUMBING PERMIT
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Blue F,c I PERMIT NO. 749 I
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(Please type or print and sign at bottom) 3 Yellow Applicant 6
ADDRESS I
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ZONING(ofifice use)
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LEGAL DESCRIPTION(office use only)
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LOT ( BLOCK 2— ADDITION1e/(c s _J
CL 5,,,,,,,44-2124/ PID 25'5d/—*
(ONaWNER F\flfl
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(Address) � "I Q�q(..� Sho(\e, C�tn /wAPPLICAN� P,1
(Name) I V(NStyllarce/ (Phone)(Address) C/CK) CA/tit 17d .bJ(1 S V ' I le/
(Address) �� ���
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(Contact Person) , A ,/ _ (`(I�
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(Phone) �� I (,�l
APPLICANT SIGNATURE
/111pP1-I---, f DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture .
Bath Tub with or without shower Quantity Type of Fixture
Dishwasher Rough-ins
Floor Drain Water Heater
Lavatory(Bathroom Sink) � Water Softener
Laundry Tray(1 or 2 compartment sink StandPipe(Washing Machine)
Shower Stall Sewage Ejector
Sinks Backflow Assembly
Bar Sink -- Backflow Assembly Test
Water Closet(Toilet) Other
FEDULE
Industrial,Commercial&Multi-family 1%of job cost with$49. 50 minimumE
Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $ qq O
STATE SURCHARGE $ $1.00
TOTAL PERMIT FEE $
(Office Use Only) .
This Application Becomes Your Building Permit When Approved Paid J„
__JJrV„ O Receipt No."14 0
Builth Date
nQOfficial 1,�zl 1y
Date ,
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372