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CITY OF PRIOR LAKE PLUMBING PERMIT
9-
1.5
lyNE50
12. col. GBlola Citye e I PERMIT NO. i ,/14-g 1
z
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS LOU)
ZONING(office use)
1aaOn C�) k M
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PM
OWNER n V i K) ��/�Ca jeer/ (Phone) a/g `7`CD'2- 7,37 g-
(Name) ! ! � n ,, /
Address l Llle0 Ce(,tU l n��-C.C.I,�' eire)eN ? Olt Lakt fr 1/V 7�
APPLICANT
(Name) )RI e(YYVZ, UV ( J ` Q0(Phone) s 58 9 - 5O
Wd.�-'y
( S MI Ich�i&O 55-
(Address) �� x(Address) (City) (Zip Code)
(Contact Person) -3-60 (Phone) 3O- 5 R9 ei'i5()
APPLICANT SIGNATURE DATE
e."-- =4141 9 -,9,9 -,L5
APPLICANT PLEASE COMPLETE BELOW Type of Fixture
Quantity Type of Fixture Quantity
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
Residential,New One&Two-Family $149.50
Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,Additions&Alterations $49.50
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $ Li 9. 50
STATE SURCHARGE $ 1.00
TOTAL PERMIT FEE $ 50 .
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid JV V�l 5—O Receipt No. 74
pat_...._
Date - /s By
$undine Official Date G
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372