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PR/04 Date
�� PRI Rec'd
A,, CITY OF PRIOR LAKE PLUMBING PERMIT
II'
'+12 ESD*
1. Blue File PERMIT NO. �+.,,'✓1 > j` i,3
2. Gold City yi! of
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID(2.1Y- • ,r
OWNER i _ -
(Name) '' , .
ame f� ` (Phone)
(Address)
APPLICANT
` l , /
r ;
(Name) 1-1=6--t:' '1 ys (Phone) '.,/.,, ,-- IF: , / )
h
(Address) 1:::). . "/ I (.V6'4'6'� /(:),(:';( I"'' ' i�`, ha i 17 ', y id `' '''' CV)/
(Address) / (City) (Zip Code)
(Contact Person) (Phone) 4 r
Vit; 9'"t r/- ,<o / r
`�ak.f
APPLICANT SIGNATURE tFrI°" 'tf ` , c%'. . .' DATE 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
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 $ Building Permit#
PLUMBING PERMIT FEE $ 467„c0
STATE SURCHARGE $ it,
TOTAL PERMIT FEE $ 50, 50
(Office Use Only)
I This Application Becomes Your Building Permit When Approved Paid ----D. 0 Receipt No. Tif
Date By_- c"\-- p
I Building Official Date 1 8 ° I • t S P{-`
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372