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rRto Date Rec'd
O ,. k.�> - • ITY OF PRIOR LAKE PLUMBING PERMIT
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2 . :id qtr PERMIT NO. 1 0 t 305-
1 Yellow Applicant
(Please type or print and sign at bottom) / U
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ADDRESS ZONING (office use)
O '16 fir aa 0c t'ck a ---
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER I/ /
(Name) l's, ci 1 ' e .'l 6/ L4 A (Phone) 7 V - dd 6 - / s' / /
(Address) 3O ?'' 'N/Oe Ocifc t 0 r 1
APPLICANT ,
(Name) 8 e„ j ,.'
o ,.) , n ( 4 k i rt /01 ,,, 12,`,. / (Phone) ()- _ 0 -7 c/,1 r
(Address) f i,() V 3,-- S /l/ ./ (5 7/4 7 S C e(( /
(Address) (City) (Zip Code)
(Contact Person) 0 s )1 ( v ; /' & (Phone) x L � /
APPLICANT SIGNATURE/ - -- DATE e 2 �� /
` 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 $ L ( C l• -
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ S & ` U v
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid ceipt No. O(
Date t (fjf U n /� y
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