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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
Blue File PERMIT NO. /
2.Yell App //��
3. Yellow Applicant l ✓✓✓ [ (((
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
I40/ 1 45537g 7iS.b
LEGAL DESCRIPTION(office use only) j Q (�
LOT 6 BLOCK2 ADDITION /,4!(L4r7 l/l ea) PID 07S ' z//vi 7 c4°
OWNER
(Name) ' "C7rty /'3a (Phone) 9504 l(Q"p? 7J
(Address)
APPLICANT I `/ L/ )95� 4 G5 48O3
(Name) itQid � � J moi/. (phone)95d.
(Address) d> _ 40 iI�_ _/ 1 P _.dt 4F1 / 5 37
(Address) (Ci (Zip Code)
(Contact Person) - iriI ( "� ! (Phone)
APPLICANT SIGNATURE IL14. 9!! DATE 9,& 7i 5
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 ►LUMBING PERMIT FEE $
The minimum surcharge for a ;TATE SURCHARGE $ .50
"fixed fee"permit is$5.00 COTAL PERMIT FEE $ 5C):5C)
This Application Becomes Your Building Permit When Approved Paid 77 . co Receipt No.Tq q 1
(cBY C
Building Official Date Date q>. O�j� J
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372