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p RI Date Rec'd
° CITY OF PRIOR LAKE PLUMBING PERMIT
Jannet /William O'Day
t77 2976 Center Road Southwest
41'N'NEsos Prior Lake, MN 55372
1. Blue File P ERMIT NO.
9524478708 z. Gold pp / / J53-60 3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
21 Li cem PAL d s
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) R V (/ / W L (� V 1, £L t L 0 00.9 (Phone) (60241-111-7 - 71
(Address) I lY (Al d. Svv
APPLICANT
(Name) NORBLOM PLUMBING CO. (Phone)
(612) 827 -4033
(Address)
1904cGARFIELD AVE. SO. (City) (Zip Code)
MINNEAPOLIS, MN 55408
(Contact Person) Anti (Phone)
APPLICANT SIGNATURE �Li, J DATE &/! L /
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
Q� Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 ■st $ �Va Building Permit #
"SURCHARGE" has been changed for one b
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ e500
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 51—.64
is $5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid -/s Rec p No./ j /v
Date Z� ' if
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372