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P16-2M CID o -'Ri D ate Rec'd
CC > CITY OF PRIOR LAKE PLUMBING PERMIT 8 ZS I O
41 /NNEsdo .
1. Bole File PERMIT NO .
2. Gold City /O 7Z4
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
aM beb Ca Trak) N 1Ai
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID -
( OaWNER 6( bii\ (Phone) (O I U – ��� 1 - � `��
(Address) c9 6' I�')cc*4 Th \ N AJ
APPLICANT II�� ( 1'''� y�
(Name) ��9 (Phone) � \ " \ 1 �Th v�
(Address) __. 'D OV V\-J • r S \N Z,- Y\ 31 �) �, (Addr 1 (City) 1� (Zip Code)
(Contact Person) Q,flft.1U (Phone) C fl • ( 1 I
APPLICANT SIGNATU' � �, �1i� ; 'V kill 1') 1
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 $ 119.9
STATE SURCHARGE $ ,t ,.es6-
TOTAL PERMIT FEE $ SO
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 62/ ,5 -b Rec' s No. 6/ K
Date 1 r 60 B
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