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CITY OF PRIOR LAKE PLUMBING PERMIT 0
File
Goo PERMIT NO. /5--/ /32'llr
• z.cola City /
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
/55/55ecz Erco6do L4 /V 55373-- R 5 IS
LECT4L DESCRIPTION(office use only)
LOT /BLOCK ADDITION �/ it_ • �j'�� /') Q PID LS^"36 7'D 16-0
OWNER L 'th1'- ill o r .3 (Phone)(V l d--43d-741 J
(Name)
•
(Address)
APPLICANT _
(Name) A�lia12850c Chestnut d111C.( Phone)
(Address) Shakopee, MN 45379
(Address) 952-44 ;03 (City) (Zip Code)
(Contact Person) /l . •It( ~ w (Phone)
' APPLICANT SIGNATURE .4111 ` /. r , DATE ie gg L5
' APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower 0 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
The Minnesota Statutes§326B.148 $ Building Permit#
"SURCHARGE"has been extended 171< 4.
The minimum surcharge for a PLUMBING PERMIT FEE $
"fixed fee permit-is o$'
STATE SURCHARGE $ L ®D
f/100 .TOTAL PERMIT FEE $ 5 7)
This Application Becomes Your Building Permit When Approved Paid Receipt No. 3 2.,3
Building Official Date Dati 0..Z6. ( S� By 5
24 thour.notice for all inspections(952)447-9850,fax(952)447-4245
_
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372