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• 4PR/04, Date ReedN i CITY OF PRIOR LAKE PLUMBING PERMIT / Ls--
kNESD�
I. Blue File
2. Gold Cay /, ---
PERMIT NO. e /I
3. Yellow Applicant i
(Please type or print and sign at bottom)
ADDRESS
. ZONING(office use)
9-- 7(43 e r 1 Lk e- Pc' `R is 6
LEGAL DESCRIPTION(office use only)
L OCeDIT PID ;6---; /33--(0.57-&
OWNER f ),
(Name) n _�
�[`7 0 Gun-c----el (Phone)
(Address)
APPLICANT ,---
(Name) 1e. e /,-irt P/ 1; (Phone) (P/c72`22 " Li /C3-
(Address) 3001. P� 1 5Qi? Pt- AV V-i--insloct- „5.50:
(Address) i (City) (Zip Code)
(Contact Person) To-ni-- ! - (Phone) $474
' N iAPPLICANT SIGNATURE --1...--y,/ 6111DATE 4...'2 ( �—1 3�
APPLICANT PLE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 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 $ q . ev
Building Permit#
PLUMBING PERMIT FEE $ /--9./ ....TO
STATE SURCHARGE $ $1.00
TOTAL PERMIT FEE $
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 'J^`� J 7 Receipt No. .. qg
Date By
Buildine Official Date P• s 1(0. l ' W.
24 hour notice for all inspections(952)447-9850 lY
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372