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O� PRI +P DateRec'd
CITY OF PRIOR LAKE PLUMBING PERMIT t , l �^
dr she
I. Blue File
2.GollPERMIT NO.
City �f//✓1/D �.yl
(Please type or print and si 3. Yelow Applicant
gn at bottom)
ADDRESS �/G7 7 era (/ ZONING(office use)
LEGAL DESCRIPTION(office use only)
LOT if BLOCK C� ADDITION AP-[ a `'/et '? PID ' ",373`URJ "0
OWNER
(Name) L) e
(Phone)
(Address)
APPLICANT
(Name) , J) (Phone) 40/.2.-POOP
(Address) <St Z 2 a ffitt L. v' 14 k 3rT ?- p
,� /(Address) (City) (Zip Code)
(Contact Person) 7`�'l sr
(Phone)
APPLICANT SIGNATURE Lata' i DATE CaP' :.
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixtureuanti
Bath Tub with or without shower Q Type of Fixture
Rough-ins
Dishwasher Water Heater
Floor Drain I 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
The Minnesota Statutes§326B.148 $ Building Permit#
"SURCHARGE"has been extended
The minimum surcharge fora ?LUMBING PERMIT FEE $ 9-0
"fixed fee"permit is$5.00 NATE SURCHARGE $ p
TOTAL PERMIT FEE $ -
This Application Becomes Your Building Permit When Approved r9)it-L1- Receipt N .
-��Da �
Buildiu¢Official Date t 3 <,� BY
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372