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CITY OF PRIDR LAKE PLUMBING PERMIT ,//�
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• "�'NES��A t. Blue File
2. aoia c„ PERMIT NO. ��
. 3. Yellav Appiicanl
ease or and sl at bottom
ADDRESS • • ZOlVING (oEfioe,ue�
� i�� T�n���l-� �.�,r�.
LEGAL DESCRIPTION (o�6ce use only)
L4T BLOCK ADDITION PID
OWNER h �',� /
{Name) ��il 7 . �U�l r � {Phone) lY � " U�� "��
(Address) I 11�1 �C,J ka0 � ��
(Name �� V l U� r � ����,Phone) g��-7��1 7�7 T
(Address) / ! 4d w - � �i ,/l�� �Y -L � �
(Addz�ess) (City) (Zip Code)
(Contact Person) i� �(Phone} "l-� `� yS - y � y %
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
QuanH T e of Fixture uan� e of Fixture
Bath 1�zb with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink Stand Pi e ashin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stall Backflow Assembl
Sinks Backflow AssembI Test
Bar Sink Lawn S rinkler
Water Closet Toilet Other
FEE SCHEDULE
Indust�ial, Commercial & Multi-family 1% of job cost with a$49.50 minunum ResidenBal, New One & T�vo-Family $149.50
Residential, Additions & Aiterations $49.50
'E'he Minnesota Statutes § 326B.148 � � �st $ Building Permit # �
"SURCHARGE" has been changed for one pLUMBING PERMIT FEE $ �1 ��
year effective �
.Juiy i, 201�, untii June 30, �0I 1. STATE SURCHA,RGE $ �'.Do �$Q
The minimum sureharge tor a°tixed fee�� permit TOTAL PERMIT FEE $ �� ��
[s �i, 6eginning July 1, 20]0
This Application Becomes Xour Bnilding Permit When Approved .".�. Paid. �, / -::: Ite e'pt No. :(� �
_ ,,��. s� 0��
' Date
B�a�e ortt�i na� _ _. �-, �('•� � �
24 hour nodce for sll tuspections (952) 447-9850, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mlnnesota SS372