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CITY OF PRIOR LAKE PLUMBING PERMIT Z. , 2 . 7, v 9
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Blue File PERMIT NO. 09,006 k''.
3 Yell A
3 Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
4s 9 g 1- rn m orls b ur Tka,.% 1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER LL
(Name) A-e.v 2. JGH M A 1 +Z _ (Phone) L9 12- 201 813 S"
(Address) 1 -}69 q 1- ivonA111)b011- d Trc... , 1 ME 1.ca.k-e, MO
APPLICANT M N r p ,
(Name) tU'1M 61' 't. Repol r► c- • (Phone) ci&:) qS W N y
(Address) 1 W • 3 OJ..k _ ShC0 � S5Slcj
/��� Q �(Adddress) (City) (Zip Code)
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(Contact Person) I Ou_X_ Ct)-1 l W b tot (Phone) CS` 9" '11Y (
APPLICANT SIGNATURE r-- DATE
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 $ 4 ..5
STATE SURCHARGE $ .50
TOTAL PERMIT FEE $ So, do
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid UL Receip N .572 $/
Date 2- o B
Building Official Date ( /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372