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04 ?IN Date Rec'd
PLUMBING PERMIT
Le
te CITY OF PRIOR LAKE PLUMB
silNNEso l- 1. Blue File
— 2 Gold City PERMIT NO. 10 (0 4,.,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Na \ � -- l (Phone) OtS L ®-l.Y 'iV
(Address) a ' ` arre\)t DV' 1 l,.lD 1c\ -Ci t 5S
(Name v ' --mil, l ►' (Phone) T 4� 1
(Address) 9 S IlOttaaph 1\- althAPt
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(Address) f ^` (City) , (Zip Code)
(Contact Person) t D N Jl J (\ Phone) Y �`" -
APPLICANT SIGNATURE At 0 1 ' i 1 , ` 1 , DATE 31 27_11 0
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 $ 4c.`SO
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ .00
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paid 572 D i 1 Rec, o.5-9 G J'4
Date �, i 0 key U
Building Official Date '
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 a
4646 Dakota Street S.E., Prior Lake, Minnesota 55372