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° � � ; : ' t 4' CITY OF PRIOR LAKE PLUMBING PERMIT C/
r/
Jn'NESUS //
I. Blue File PERMIT NO . ! /
2. Ye App 2 .7 3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS SG ZONING (office use)
(e at -I-- mad-en Or Pri Or LdQ / 55- 7z
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Na Al 0 Dk,t CW (Phone) ✓ ! DO
(Address) (0 224 Amy IU 1 Ct I SE (7) I _ L� y,,, / 1/J V .!'' 2-
APPLICANT � Q j, � / �, C�
(Name) / L Ci (Phone) l l5 JBtp S to
(Address) 1 l D Dr -1rilAi W' 5
Addre (City) (Zip Code
(Contact Person) j 1 m , . . & (Phone) 715 L 8( SLP. 0/
APPLICANT SIGNATURE 1 7 I /ZIC....__ _ DATE 1 1 Lt ((
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 $ 1 00 I D° Building Permit #
PLUMBING PERMIT FEE $ 6 ( ;X)
STATE SURCHARGE $ 50
TOTAL PERMIT FEE $ Sf
(Office Use Only)
I
This Application Becomes Your Building Permit When Approved Paid .6-6' VV Rece No. (e7e
Date /, // // By
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