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PRIo Date Rec'd
~� CITY OF PRIOR LAKE PLUMBING PERMIT
A
tfI NNESO CA
I. File
Gold 2. GoIA City PERMIT NO.` 3 os l
3. Yellow Applicant 1
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
4/ O + u t:,,,H.• - t u b i rd Tr. M. E. Pr ov • L c*e
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PM
OWNER t'a'' ct �- arStie5 (Phone) 6 152_ 2_33 1,30
(Name) + 1 T. 'Frio
(Address) 4-1p T 44tJh,wt i ►� a b i rd Tr. fI , G-- v Lt '.
APPLICAN v
(Name) rC l � pro 1171M 1 k (Phone) C1 ,J 2- q (o'?
(Address) Sa 15 ZO c1 St . Lc L.e v i 11 e 55 04 4 1-
(Address) (City) (Zip Code)
(Contact Person) �Zb o r Sri 5 , � I its (Phone)
�- q q q�
APPLICANT SIGNAT • 4 i
' ■
DATE 4 • 20 '' 1
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
i 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 § 32613.148 �sf $ Building Permit #
"SURCHARGE" has been changed for one ,5 D
year effective PLUMBING PERMIT FEE $
.July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5.60
The minimum surcharge for it "fixed fee" permit TOTAL PERMIT FEE $ 54,50
is 15_, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5* 5 - 0 Recei t No.(
Date. 7i ( B
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