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A CITY OF PRIOR LAKE PLUMBING PERMIT .Z , q
INNEsd`" ]. Blue File
2. Gold City PERMIT NO. /Z 0 �/ &
3. Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
U9 I Wi tI ovvw ood 'of SW
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWN
(Naam (Lei Cc 1 PfJ2�Ofl (Phone) q 5 2 W7- 3
(Address) .G(irli_e j 1 n or Laki4 VY N• S17 2
APPLICANT esk) I _ (05 - 124 (Name) ` m •' A , l .I ■ (Phone) b5 l - g 0
(Address) b ■ 4. L*, .I PIN / N % ( 2-
(Address) ' ity) (Zip Code)
(Contact Person) k S (Phone) ('5 ( 1 -N(5 -1 Y[0
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APPLICANT SIGNATURE / DATE Z 7 - I Z
o
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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 $ 1 4 - Ci . 50
STATE SURCHARGE $ 5 O.
TOTAL PERMIT FEE $ d
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ..57 S - Re pt No. ( /J
7
Date ,., / D, , rZ B
Building Official Date C' - •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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