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a CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue Cie PERMIT NO. 1 j _Li
2. Gold City
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
OA t Rocky\ vie-AN Vd . "
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) 5 eff Ck /` A \404 t (Phone) 5 - 7 1-4
(Address) C 5OX \Q) i 1\or IA,4 Y Y b Y)-1 pS
APPLICANT �� � 2�
(Name) _ AA ..V..� ( • ► . A 1 • (Phone) ' — �/ VJ J J 0
(Address) 7-)110 OecA4 Q Y Y (' k\ . C)1 2 � (Address) (City) , Code)
(Contact Person) �� C ) (Phone) S51 - � I fo
APPLICANT SIGNATURE .I'________ "__J;.4fZt/),,32% / DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher `I 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
Sidq Residential, Additions & Alterations $49.50
Estimated Cost $ , 5 Building Permit #
PLUMBING PERMIT FEE $ t4G1.50
STATE SURCHARGE $
TOTAL PERMIT FEE $ 5(-1 5 b
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date 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 u(1
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