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Date Rec'd
E-, CITY OF PRIOR LAKE PLUMBING PERMIT ��
h, 7
�INNESD�P
1.Blue File I PERMIT NO.d9461
2. Gold City 0
3. Yellow Applicant
(Pleasetype or print and sign at bottom)
ADDRESS
ZONING(office use)
r1141f2 01I6woocP (--f,
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLI)AN�s p
(Name) v br.4 (Phone) '763 — 236 " OZo$
(Address) /qy c Zhu
9ewu a t 6(v it S, Cp.4tlo#;e"�e r�� 'SSoa8
(Address) (City) (Zip Code)
(Contact Person) -1 /M UZ0()lt! ^Z Z-4/
(Phone) ---/(o 7) '225 6— OZO ff
APPLICANT SIGNATURE DATE I t 17 /p
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 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 $ 11. ,T
STATE SURCHARGE $ .50
(Office Use Only) TOTAL PERMIT FEE $ 50 , 0 )
This Application Becomes Your Building Permit When Approved 1 Paid ga. eV Recie o.
Date 7 �.r
Building Official Date l ?. U
, .
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372