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OF PRIOR LAKE PLUMBING PERMIT f/-0-/5
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0tCITY
I. Blue File
2.cold city PERMIT NO. (J//�J
3. Yellow Applicant `� /�V
(Please type or print andnd�signig�gnjat bottom) ,� f
ADDRESS `T z0 5 1-0/ .�-J �7 /1 ZONING(office use)
LEGAL DESCRIPTION(office use only) /,�l
LOT BLOCK ADDITION PID 2S . g35� oo `d'
OWNER /�Ai �ln�'l! (Phone) �� 7� 5��
(Name)
(Address) 5/1NC 45 COVE
APPLICANT
(Name) (Phone)
(Address)
(Address) (City) (Zip Code)
(Contact Person) (Phone)
APPLICANT SIGNATURE DATE //t0(/ST
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 1/- 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 $
________44rho
STATE SURCHARGE $
TOTAL PERMIT FEE $ 501,
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.3 3(
64
Building Official Date Date t I f,�` 1s By �
24 hour notice for all inspections(952)447-9850,fax(952)4447--44245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372