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CITY OF PRIOR LAKE PLUMBING PERMIT
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I.Blue File PERMIT NO
2.Cold City .f -// ?
3.Yellow Applicant �/'[
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/VJt P ' 11'L9 baie3 &/atIZ t
LEGAL DESCRIPTION(office use only)
LOT 'BLOCK/ ADDITION 6?-‘c..,4-A'(4 PID Z-S— 051Z..—60'5-'6
(Name)OWNEA f/'/�� 6(L>!�/1/1 (Phone) Q52—'99.S 1s 7Z4,
(Address) /91/0 U led/A4 ®as ea,
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APPLICANT ,/
(Name) //'D//l Cr y/f'/a/ (Phone) 7/5 j4d-,‘6`7 y(Address) 3 vv& JO /C/alio ) �.. 51/0/
Add ) (City) / (Zip Code)
(Contact Person) CJI'! d 6�/-� (Phone) 7/S3�1 -AO" DV
APPLICANT SIGNATURE ,h- L.4%e%> _ DATE 9,10.4t
• PPLICANT 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
v Residential,Additions&Alterations $49.50
Estimated Cost $/1?( `J Building Permit# 1 ne Minnesota statutes g 3Gb13.14ts
PLUMBING PERMIT FEE $ e, "SURCHARGE"has been extended
STATE SURCHARGE $ � The minimum surcharge for a
TOTAL PERMIT FEE $ ,5-8. 6-4) "fixed fee"permit is$5.00
(Office Use Only)
r• ... nn ire w en
This Application Becomes Your Building Permit When Approved Pato
95 / By
mi Receipt No.
Da
Buntline Official Date CV,Z. / s /
24 hour notice for all inspections(952)447-9850,fax(952)4447-4(2245 `U��/(
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372