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NCITY OF PRIOR LAKE PLUMBING PERMIT
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Blue File
2. Gold City PERMIT NO. 15. I�,
3. Yellow Applicant
(Please type or ADDRESS print and sign at bottom) ZON$IG(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCS ADDITION �711GG�I/e PID 2 -5616-031-/-
OWNER -56to- 37OWNER 1 /
(Name) F-)rk-v L/ cJt'd (Phone) /a 5• m I
(Address) S Z -7 0.-A)
(Name) 1 &)S Pr-e> F`t)>1n1OJ.&/c LL4:(Phone) 6.7/Z 7 / L/ 15
(Address) 1171 j5- ./•,) e r r . /V, S A a rn� 3 f
(Address) (City) (Zip Code)
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(Contact Person) I c A A)C)�' O (Phone) c</'L 7 2() //5 3
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APPLICANT SIGNATURE DATE _2/4/L5
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
l3ath 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 (F V B OA-)
I
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 $ Building Permit#
PLUMBING PERMIT FEE $ 1/9 .�b
STATE SURCHARGE $ $1.00
TOTAL PERMIT FEE $ 56 e ca
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 0Receipt No./VA
Date ` By
Buildin¢Official Date
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372
a,k S _ 47517 y2V5