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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2 Gold City ` PERMIT NO . // . / /30y
.
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Is1 +0 Ccu- - Cove - ray1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
B r 1 �n k V S S a /(� T U -(D lD
(Name) - (Phone) S E
(Address) 15 C
1+ 0 0 - - V A // 0--VA 6 Co V c 1 -t r & j ' j P r o f - Lc�k.'e_ J - k1 1 2..
APPLICANT RaCCiM Qh t - \r -e P1V(Mh.jn ` ‘1Z.- 2- OS- _ °(0..
(Name) N r o (Phae) C
_— = ■• - = �_, �a h h/Viki �S S2-7
(Address) =��1 l
13i 1 1 ( 6 . i1 i i I n 1\I) (City) I / (Zip Code)
(Contact Person) 0 -e_c `{ �-hrt re (Phon `�'ZU J `ALL U U
APPLICANT SIGNATURE
S ) 1 2 - Il /II
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 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.148 'ost $ Building Permit #
"SURCHARGE" has been extended �- U
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ - S, °P0
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 5 -f • S 0
This Application Becomes Your Building Permit When Approved Paid S - U c kipt Nq.
Date i t
Buildine Official Date 1 Z ` 1 '
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372