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O � pRlp� Date Rec'd
F CITY OF PRIOR LAKE PLUMBING PERMIT /U. � L�/ Z
v �
�� '. B '"` F11 r PERMIT NO
2. Gold City ( • �z . / ���
3. Yeilow A��licani
ICaSC OY � t Sila S� St bOtt4M �
ADDRESS ZONING (ottice use)
� � 1 � � ,� L
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
�� C 10'� r�y� �obb; �"'r"� (Phone) / � Z — Z1-( — � � �o
(Address)
APPLICANT c�
(Name) �a t rc 2 `(� � v rv��- . � (Phone) / 5 Z " 2' � 2--� � �p3�
(Address) ,��to� LVC�.�(,b Lr� ��°� l�u�-^ ���''�.
(Address) (City) (Zip Code)
(ContactPerson) A-r�mr- (Phone)
�
APPLICANT SIGNATURE DATE � �
APPL ANT PLEASE COMPLETE BELOW
uanti T e of Fixture uanti T e of Fixture
Bath Tub with or without shower Rou h-ins
Dishwasher } Water Heater
Floor Drain Water Softener
Lavato Bathroom Sink Stand Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
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 $ � S �
STATE SURCHARGE $ ,s.6�--�8�—
TOTAL PERMIT FEE $ � , S�
(Oftice Use Oaty)
This Application mes Your Building Permit en pproved Paid �� S --v Rece' t o. �.73 S
U ( '1� ( Date� � , � Z . BY
snilaing ta1 te
24 6our notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372