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CITY OF PRIOR LAKE PLUMBING PERMIT // Z q i 1
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i+VNESO�
'. B'"` File
2. Bold City PERMIT NO. I it ; / es---
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS . � �� , _ A' �� �� � - ` ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( O I � a WNER }B L kaA + (Phone) qSa a33 H3q
(Address) A c9. d. 1, \AS -e Q
APPLICANT + l i r� 4 . r S V Y
(Name) (�l{1�1�2 Sb Cry 1 p � (Phone) 6 ��
ll � 1.3
(Address) ) — 1 � t C � `T"e---Q - ss °)
(Address) (City) �, (Zip Code)
(Contact Person) ) 11 \L 1,L '0 \_ i PCilXY � l A ' � (Phone) q,%LlY Li Y 1
APPLICANT SIGNATURE ' DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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 I% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326 ist $ '5 Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ L fq. Co
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 55. 00.58
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 'j't. 7
is S'S, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 3 - q S --v Rece' 't o. 4/7/ 67
G
Building Official Date Dat By ,
e, 1 7i-/ (
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -42
4646 Dakota Street S.E., Prior Lake, Minnesota 55372