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CITY OF PRIOR LAKE PLUMBING PERMIT
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IVNESDCP L Blue File
2. Gold city PERMIT NO. / / 13 i1
3. Yellow Applicant �U
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I l i 2 (p LF Shore Lan-c.. 1.1 L.•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name V on Q l A 33 rd 0-0 (Phone) q Sp9s 9 L i S) 2a)
(Address) ) W (D Share. Lae-. I P lx l,o Le. 14,3
APPLICANT
(Name) l M t'(1`n G 40.. I ' urnl�t nn $ 1 c l 1 (Phone) CI Sa y Li y Li `/ t /
(Address) 1/ ( -#` 3. 1 r 1 LX ol O. -e— 0-4 ..e_c_ SS-11 c 1
,� 1 c # (Address)) p / (City) (Zip Code)
(Contact Person) PO �kA t,0& [ PQ^ F S!�i{Y (Phone) Q-C c ' y V I y
APPLICANT SIGNATURE _ 1' 1..17'6 DATE /a ' / S — / /
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
The Minnesota Statutes ¢ 326B.145 .. Est $ q5b — Building Permit #
"SURCHARGE" has been changed for one ��
year effective PLUMBING PERMIT FEE $
.July 1, 2010, until :June 30, 2011. STATE SURCHARGE $ S. do o
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ cj #. Sb
is Li, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid s-, /_ S te,) Re ipt No. 6 c 4 ( Ci
Date B
Building Official Date ( 2- 2 J - i '
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372