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O D ate Rec'd
¢ 4' A � CITY OF PRIOR LAKE PLUMBING PERMIT ( Z (/
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4,.NNES. .,, I. Blue File
Z. Gold oily PERMIT NO./i
3. Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
M S (� t- \Y \G,-.i
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) D f.,,--/ L V:,. e,, A S (Phone)
(Address)
APPLICANT
(Name) 1 r r P v r.A. i . , - , ) ✓� ( . _ (Phone) 5 - (-) X17 - S I
(Address) 6 y00 1--1, 1.. Q. "-4 1 „t•-_, 1 Q c- , t i L....k (�/J ,5 �1,
(A (City) (Zip Code)
(Contact Person) ! J °^'--. C, i a ,-, ∎ (Phone) 6/ 1 - y if 3 • °1 - `i
APPLICANT SIGNATURE \ ../ j L DATE C. l x-3)1 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
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
” ' ' ' — 1st $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $
year effective STATE SURCHARGE $ .50
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid `7 j S Z Rec:1 Nq! >/#
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Buildin¢ Official Date Date , Z /( ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372