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PR1o� Date Rec'd
rof a \ ,1 \ CITY OF PRIOR LAKE PLUMBING PERMIT 3 1(0. Ob
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I. Blue File 0 PERMIT NO . Z
2 Y eII City / /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
6 2 2N-1 Mitt- [el C, esc 1 E SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) A 1rter4CO Q' CiCCI" (Phone)
(Address) (, 2,2M tiAr 1<'\ C I 1 C S E
APPLICANT j
(Name) 5'IG In ry-C P '�" (Phone) 'V2--3 bl — o l2r
(Address) E 5 +4 S-4' s'„ 4-t 10 C t !laS I4CI S S31
nn �,, (Address) (City) (Zip Code)
,4 (Contact Person) 4t.h (Phone)
APPLICANT SIGNATURE _ /,, DATE 3-11-or
• APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher f 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 $ 75&oi' Building Permit #
PLUMBING PERMIT FEE $ 1- 1 4 1Sd
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ 564.00
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid5 0 00 Recel o. 6 -z*,
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Building Official Date Date 2. O
24 hour notice for all inspections (952) 447 - 9850, fax (952) 447 - 4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372