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r6c-PR ION, V Date Rec'd
PRIOR LAKE PLUMBING PERMIT
CITY OFO /0. /3 .
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1. Blue File PERMIT NO.
2. Gold City
3. Yellow Applicant /✓ '(/ G�7
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(Please type or print and sign at bottom)
ADDRESS , A' ZONING(office use)
/0 t /P` l�— IvN
LEGAL DESCRIPTION(office use only) VII / p
LOT �BLOCK / ADDITION -� /r(/!/ S� `}LA PID 25- 3O' -
OWNER u ;��,,�, f , q
(Name) 6 d TO t J �/�'c i'l L (Phone) �L(Z-iiq-
(Address) Z S1 11 Der_r/VT IZ — N Vv
APPLICANT �j
(Name) �� (Phone) `'7 c 2- , -too 0
(Address) 7'7/0 0 13 Eu'OM VI lil.'e- S S 3 3'7
L (Address) (City) (Zip Code)
(Contact Person) e 4 -- (Phone) 'S Z--7(0-7 I �(`l t c'/
APPLICANT SIGNATURE la.24'1 I DATE 1*I(-
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
I -3, Z 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 $ 1411 , Building Permit#
PLUMBING PERMIT FEE $ -4G1. cc)
STATE SURCHARGE $ $1.00
TOTAL PERMIT FEE $ <O. co
(Office Use Only)
This Application Becomes Your Building Permit When Approved Pai V j� c0 Receipt No.3/
32
Date By
Building Official Date ( 0 , t'
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372