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PRIG Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT I o
7
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�b '� PERMIT NO.O I M12.•(Please type or print and sign at bottom) 3•Yellow App�ican[ ,
ADDRESS , (office use)
I c P Cfl Frain 1 Trc,,; 1
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER h 1 v 1
(Name) n 111 To. 1"jV1Q.t'' 1 (Phone) S9 0 71 -').
(Address) 1 IP`f q') ii o.-d k) r,Tret.,,
APPLIC4IT Il _ q
(Name) �Iv\tt`11 r lvw,�tr� r F-�( 't/y� (Phone) !1 /LIS-y��Y
(Address) )L1� �i.�,(� �C��(�p SS3 ")
(Address) (City) (Zip Code)
(Contact Person) P .011.1/` U J (Phone) 9 cd- y L!
APPLICANT SIGNATURE /aSkDATE /1 ,—O
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 ap r Z e rt f'.ea,
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 $ 'H.So
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 50 , (3
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid• `V Rec t No.590
e
610
Dat a
$ a w
By
Building Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E„Prior Lake,Minnesota 55372