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e CITY OF PRIOR LAKE PLUMBING PERMIT 9
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Blue Cit Fi P ERMIT NO. -�
_. cola City � . 7
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
OWNER 0
(Name) v■vr 1\\.0 r \ oC V- (Phone)
(Address)
APPLICANT -
(Name) 1tr k e.r NA....bk -"Cr C (Phone) 5 L i 75 9 i d
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(Address) . • w `
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(Address) (City) (Zip Code)
(Contact Person) ► 1,, (Phone) SC.4.-w�..
APPLICANT SIGNATURE fiL✓'ti.-- DATE "1 —, " 1 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
1 Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
1 Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
1 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 $ la POO Building Permit #
PLUMBING PERMIT FEE $ 1 0 0. f Milia
STATE SURCHARGE $ S., 60 l Z /0
TOTAL PERMIT FEE $ /05 0 0
(Office Use Only)
This A / • ,t / Becomes Your Building Permit • n Approved Paid ` J O5 Y (� Receipt No. 6,73
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�Isne1 Da e
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372