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CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File
2. Gold City PERMIT NO.A 10
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3. Yellow Applicant I
(Please type or print and sign at bottom)
4ADDRESS ZONING(�fleiceuse)
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(COL'�-�'CkeS76--- C
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LEGAL DESCRIPTION(office use only)
LOT/, BLOCK-1/ ADDITION PA + - )U(C�4.-‘-_6-1-- A-.- 11,t E(u1.1 PID 25- Ces3•40
1► :me R !`�T E.- -t t -tJt Ir. S (Phone)
(Address) 4€4435--
/99,e Di Com' eGcl /ii-ag- s,- /'72/t3te 61,-- :
‘31-;LICAN
(Name)//
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` ! k l ISG56.4?--0(3 -17-z;^ - (Phone) 7S 3- 47 7— 9 S
ess) 3P40 c. F-FgIZ�C"Ii-ti . A.)- sit /Yt/ell c- rmit i 55 3 7 6
(Address) (City) (Zip Code)
(Contact Person) M/
/44 got) 74 3-,07 FS6 - 344 4
,,,,,,,„/:......„--- #00........„. ' (:2 -G7"''.3APPLICANT SIGNATURE
__- APPLICANT PLEASE COMPLETE BELOW 53
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher Water Heater
Floor Drain Water Softner
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 )X Lawn Sprinkler
Water Closet(Toilet) Other
FEE SCHEDULE
Industrial,Commercial&Multi-family 1%of job cost with a $39.50 minimum Residential,New One&Two-Family $99.50
Residential,Additions&Alterations $39.50
Estimated Cost $ Building Permit#
PLUMBING PERMIT FEE $ 36 l_ 'So
.. STATE SURCHARGE $ .50
TOTAL PE T FEE $ q O_ —
(Office U' r,nly)
Thi• . i p ,r+ !�, ' i
P�s Your Buildi g 'er t W en Approved Paid Recei.t No..3 `^/
-, A.,.i�'� 6 63 Date ' — By (S
Building 1 'c': ate
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
16200 Eagle Creek Ave.,S.E.,Prior Lake,MN 55372-1714