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CITY OF PRIOR LAKE PLUMBING PERMIT
41INNESQ`ct~ 1. Blue File PERMIT NO.
2. Gold City PERMIT /3 / 7
3. Yellow Applicant •J
(Please type or print and sign at bottom) ZONING (office use)
ADDRESS _
1 WI/1J) J I'rn beX Cresf hr. SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER N e ,r kJ 6 (Phone) 1 I ✓ ^ �, ✓ - L V
M o3Ctv1
(Address) 7601-LAY-a, M N - 5,Y) ,
APPLICANt , ,
ame aimpkOn VI U,MAQ ( (Phone) trf) —I D ( 1 S q V
(Address) 1 _ ' a A f . —Awl -.A All i
(Address) ( ity) �j (05- ( p Code)
(Contact Person) I (Phone) / 1 3 ' 3,Lk
APPLICANT SIGNATURE
D ATE 2, 26- 1
APPLICA PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Roug -ins
' Dishwasher Water Heater
Floor Drain 1 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
,ost $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ i--\-c'
year effective STATE SURCHARGE $ j , 0650
July 1, 2010, until June 30, 2011. TOTAL PERMIT FEE $ )L1 , ��
The minimum surcharge for a "fixed fee" permit
is $5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid Receipt No.
Date By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 1