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3. Yellow ApplKUm
Please e or t and si at bottom
ADDRESS ZONING (oetice nse)
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LEGAL DESCRtPTION (oflE'ice use only)
LOT BLOCK ADDITION PID
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APPLIC I I� ,�
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(Address) � �� � � �_ '���'���I 1�! �' ��L1� � � }� �� l ��.-c�� /Vl t�l �5�� Z
(Ad ss) (City) (Zip Code)
(Contact Person) C 1 "" -� � � ��' �.� � ° �1 �� �
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APPLICANT SIGNATURB � DATE � '
APPLICANT PLEASE COMPLETE BELOW
Quanti T e of Fixture uanti e of Fixture
Bath 'I�xb with or without shower Rou h-ins
Dishwasher Water Heater
Floor Drain Water Softener
Lavato athroom Sink S#and Pi e Washin Machine
Laun Tra 1 or 2 com artment sink Sewa e E'ector
Shower Stalt Backflow Assembl
Sinks Backflow Assembl Test
Bar Sink Lawn S rinkler
Water Closet Toilet) Other
FEE SCHEDULE
Industrial, Commei+cial & Multi-family 1% of job cost with a$49.50 minimum Residential, New Oae & 1�vaFamily $149.50
ResidentiaF, Additions & Alteradons $49.50
The Minnesota Statates § 326B.148 ��st $ Building Permit #
"SURC'[-lARG�" ha.s been ehanged For one ¢C �r--U
year eifective PLIJMBING PERMIT FEE $
.tnt,v �, 2oio uf�tit .7une 3Q zo� �. STAT'E SURCHARGE $ S-
The minimum sorchArgc for x"fixeU fee" permii TOTAL PERMIT FEE $
is ^�5, begFnning Jaly 1.2010
This Application Becomes Your Building Perrnit When Approved Paid�� �T� Receipt No. ���� Z
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Date �� . � Z By
BuildiaH Otflcial Date
24 hour not�ce for all inspections (952) 447-9$50, fax (952) 447-4245
4646 Dakota Street S.E., Prior Lake, Mirmesota 55372