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CITY OF PRIOR LAKE PLUMBING PERMIT
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2.GoldPERMIT N �/n7.YelllAiry O: O tC2.5ow Applicant �L/
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
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LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID a-S-' 565 . od Y`00
OWNER
(Name) yLk,_&,
(Phone)
(Address)
APPLI(NameCANT �46,9 ,s,,,, ,
(Phone) o) O b(1Y95
(Address) �2 2 1914 /i. / iw� ��
(Address) ( ity) (Zip Code)
/36(Contact Person) U)) IC (Phone) (f y 4 l p/i V it
APPLICANT SIGNATURE -- ` ' ` '' DATE " t/ 1
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# file Minnesota Statutes§ 32611148
44SURCHARGE" has been extended
PLUMBING PERMIT FEE $ `,j The minimum surcharge for a
STATE SURCHARGE $ (J fixe(fee" permit is 2.S.UO
TOTAL PERMIT FEE $_5(97; _ ,, d
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid a �J-d Receipt No. tl G 15
Date ` k.co By ``7
,�`-
Buildine Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372