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,� . t ' CITY OF PRIOR LAKE PLUMBING PERMIT
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2. cold n PERMIT NO. � - /i y
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1'1'01 bovy, L+-- NE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID ' '
(Name) WNER kt e'f E (' t L Lei v\.,, (Phone) CU I� l(/k l ! 7P
(Address) 1' - I 11 hAie., C-4-- ./t/
APPLICANT 'y� �f 1 GG� /�
(Name) Aihtt Ac -- i OVS/'Oa,, FMAk44 P1 (1hone) 6) - d - t -3 `4i
(Address) 1 1 0. 11 1 ? CI E / V / - ` plf I AA/ v ' 1 I
//tart (City) (Zip Code)
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(Contact Person) , ✓ �. i �1S( (Phone)
APPLICANT SIGNATURE #� (� L1,�'(�%f,,� DATE gAJ ! it
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou • h -ins
Dishwasher 1 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 I
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 r 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 TOTAL PERMIT FEE $ Su . s`DI
is IS beginning .July l, 2010
This Application Becomes Your Building Permit When Approved Paid - ; / 31 Receipt No. i 143
Building Official Date Date ` , / 7/ 7,6-+---7--/
24 hour notice for all inspections (952) 447 -9$50, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372