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Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 3 2
1. Blue FilePERMIT NO.
2. Goldi W • 7j
3. Yellow
City
Applicant Y! • ‘""1•.•1
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
i 1424624 4)4141 &Jae_ A J NE
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER \/ 2-8S
I � Q-�f Q/
(Name) Y 1 r ) g/ fS e.-- 1 I (Phone) q5 2�iJ "Z ✓
(Address) 1 `-JI L9 L) lt.4er5 6-drke_ . �f: 1 J /Vt. c Q�(�,
(Name) L E.
f'i C-han ca,I CO (Phone) i5 1 �V I
2=7's
(Address) (D 2-0 64'" S± 1\•.) lj IJ a1/4,) Pry 910E 5 ioO7)
(Address) (CitS.5 (Zip Code)
(Contact Person) ' J Si—4t'ki (Phone)'952-275g —80(35-
, 4., - DATE 3J I
APPLICANT SIGNATURE a A i ` z4A 10
1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower _ Rough-ins
Dishwasher 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 I
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 $ - f1. 3---O
STATE SURCHARGE $ $1.00
TOTAL PERMIT FEE $ ,5 D o57)
(Office Use Only)
This Application Becomes Your Building Permit When Approved Paid 50 v 6-6 Receipt No. 44 q
Date 3J 2-0,l(, By
igke_Building Official Date
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372