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.� % � e CITY OF PRIOR LAKE PLUMBING PERMIT itt-
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I. Gold City
I PERMIT NO. I
2. Gold City
3. Yellow Applicant i .., , I (j
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
3077 Lake Haven Court NW
iz
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID i ` 3 ( t,O(e v
OWNER Dave & Nikki Miller
(Name)
(Phone)
(Address) 3077 Lake Haven Court NW, Prior Lake 55372
APPLICANT
(Name) Clearwater PIq & Htq (Phone) 952 - 440 -3779
(Address) 19260 Mushtown Road Prior Lake 55372
(Address) (City) (Zip Code)
(Contact Person) Susan Schlink 952 - 440 - 3779
(Phone)
APPLICANT SIGNATURE DATE 2
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
1 Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
1 Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
1 Bar Sink Lawn Sprinkler
1 , 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
The Minnesota Statutes § 326B.148 -Est $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit
is , beginning July 1, 2010 TOTAL PERMIT FEE $
This Application Becomes Your Building Permit When Approved Paid 3 s 7) Receipt o.
Building Official Date
- 3 B
Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372