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04 PRIO Date Rec'd
.4 A CITY OF PRIOR LAKE PLUMBING PERMIT
I. Blue File
2. Gold ERMIT NO ✓ "�
l App ✓� �42, /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I*D 91 Mil
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) t r - / 4 - a_mil. (Phone) col 12 (D P v 7 72
(Address) 11 tefrO £ 1 ri J 1 1
APPLICANT g
(Name) 12850 Chcstnu Blvd. Inc. (Phone)
p�iance
(Address) Shakopee, MN 55379
(Address) 95Z- 445-4803 (City) (Zip Code)
(Contact Person) jarn u �
'
-' rA (Phone)
Lai APPLICANT SIGNATURE �:es n ... DATE 1 3
k
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher CD 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
Estimated Cost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended 'LUMBING PERMIT FEE $
until June 30, 2013, ;TATE SURCHARGE $ .50
The minimum surcharge for a TOTAL PERMIT FEE $ £ 4..-. To
"fixed fee" permit is $5.00
____ _ ,...._—,,.. y‘.u.a«3 i our nuuamg Permit When Approved Pai t •-, t ` ( � 7 c Receipt No.j [ �/iC� g / 0
Ddt Z 1 /1 l e �-� 7)2)96 ' Building Officia Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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