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4 PRI0 Date Reed , 0 , , CITY OF PRIOR LAKE PLUMBING PERMIT „,,_,
4,,,,'IVESD „A
,. Blue Cit PERMIT NO. /2, f''
2. cold City
3. Yellow Applicant - —
(Please type or print and sign at bottom)
ADDRESS Z i Si- NE
ZONING (office use)
9 .5 N �;� p+
•
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � �_ J 6,,, ,, I
(Name) e JG n S (Phone) ( 4 3- 3 9 u
(Address) 52_9 C )--) ci w, c lam,-, 34 i v
APPLICANT 7 {'!'�OS800(o ri
(Name) / .e- -7 G c cC " e,—, ^ () e 2 Oe el (Phone) / -) 2 — 7( - 7 — 1 g ! 3
(Addr Z Z 00 t.,/ k/ / 3 / f j G., r n 5✓ ; 1( P- 5533
(Address) 7 (City) (Zip Code)
(Contact Person) i () `..5 (Phone) 7S Z ” 7( . ? -
-------
APPLICANT SIGNATURE - � DATE / 2 - Z 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
. E l
I Residential, Additions & Alterations $49.50
The Minnesota Statutes * 32613.148
st $ l O D Building Permit # Ai /
"SURCHARGE” has been changed for one YID ///
year effective PLUMBING PERMIT FEE $ 4 i
July i, 2010, until dune 30, 2011. STATE SURCHARGE $ 5 .60
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 5 i , TO
ism, beginning duly 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 s Rec 1
t No. / , i CH t
Date B
Building Official Date 1 `� 1-z_ 9 `1 I
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372