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01.R/0
Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
1 00 16-
Yh,._SO� I.Blue File PERMIT NO. ��j
��1YE 2.Gold City '5.�eif 1�
3.Yellow Applicant C/E/
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
2Rtsp
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID • M. 003 o
OWNER 7�1/
(Name) (Phone)
(Address)
APPLICANT
(Name) IC6'40 , ' (Phone) &/2
(Address) 62,y 1 & Aor- 4 /V r itifr( k\ d
(Addrre�ss)�� (City) (Zip Code)
O � .1 G'I1.
(Contact Person) /. L (Phone) 6/2—Ai
APPLICANT SIGNATURE 16/'�i DATE I/ / 1f
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 S•rinider
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 $
STATE SURCHARGE $
TOTAL PERMIT FEE
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 50 60 Receipt No. 33�
Building Official Date Date ! l + (0 't c By 371.A4.),....)
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372