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����Q� l�. BIuC FiIC
s. aoia cn PERMIT NO. �'��Il / 7
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ADDgE� ZONING (otlrce use)
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LEGAL DESCRIP'rION {ofi6ce use only)
LOT BLOCK ADDITTON PID
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{Name)�''1 t��''�.._�'1'-IA.� C �S- � l�`l�'1,� (Phone) �� � � �'��'
{Address)
APPLIC T
(Name) ti � �i- {Phone) � � �" �� �� � �,�_
(Address) � � `� Ce � �--�s'�-�' �9'is�� �C�, � � 1� b� �-'�� ���-1 �.
(Addxess) {City) (Zip Code)
(Contact Person) � S C-�'�- f r (Phone) � �� ° `"f 4� v � �"-7�'� �
APPLICANT SIGNATURE �-� DATE 7 /
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixtare uanti T of Fixture
Bath 'I�ib with or without shower Rou h-ins
Dishwasher Water Heater
Floar Drain Water Softener
Lavato Bathroom Sink S#and Pi e Washin Machine
Laund Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow Assembt Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Industrial, Commercial & Multi-family 1% of job cost with a$49.50 minimum Residential, New One &'I�vaFamily $149.50
Residentia(, Additions & Alterations $49.50
The Minnesota Statutes ¢ 32G.B.148 �� $ Building Permit #
"SURCi-IARGE" has been chmiged F�r one
year et�'ective PLIJMBING PERMIT FEE $ t� Q, Sm
.ie,ty �, 20�0 ��►�tii ,7une 3i1 ao� �. STATE SURCHA.R.GE $ .500
Thc minimum snrchargc for a " tixed fee" permit TOTAL PERMIT FEE $ _S`4.!�Q
is,�i, begFn��ing d�dy 1, 2010
This lt ti omes Yo,�r Building Permit hea pproved Paid ��� Receipt No. �� //
Zo Date Q��� By
Building O c1a1 ate �
24 haur notice for all inspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, M9nnesota 55372
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