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i P RIO Date Rec'd
e CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2. Yell City PERMIT NO.
p // — l Z.4 3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
ILMSrl Aspen kVe_`fE
LEGAL DESCRIPTION (office use only) .
LOT BLOCK ADDITION PID
(Name) OWNER To n 3 V o ` c q 5a • R33 -343a
t , �y � v
y (Phone)
(Address) i 9 i p-en � `� f jcific Lake,
APPLICANT 1 1' T a j / 1
rr 11 l i fp Q, nce Conne_C'.4'1 n ns .L ' (Phone) ` 1 -` i �U3
(Name)
(Address) 13 13 Dan (T k OA CC c 5hC1, E 65319
(Address) (City) (Zip Code)
(Contact Person) 1 — 1 74 . 1 (Phone) • APPLICANT SIGNATURE e i . Q 1 t DATE 9 -a3 -/ i
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
.CO Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 -t $ 23 W Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ . 5d
The minimum surcharge for a STATE SURCHARGE $ 734
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ •50
This Application Becomes Your Building Permit When Approved Paid b ] - s'T Re 'pt No. ( �I'2
Da - _ _�_z�., B �Q 7
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