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Marcella Borchardt Date Rec'd
RI °1p 4930 Dakota Street NUMBING PERMIT
(g Prior Lake, MN 55372
` 9 524472698
C� , t ri
INNEso - 1. lue File
z B cola City PERMIT NO. l (49Z....5
3. Yellow Applicant `
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
L/ 3D l tI otry S -1-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) FY L r( (, W borowctfr (Phone) N Z 17 . O
(Address) 'H30 Daxofeu sir.
APPLICANT NORBLOM PLUMBING CO.
(Name) (Phone)
(612) 827 -4033
(Address) p,YIp p ARFIELD AVE SO.
(City) (Zip Code)
MINNEAPOLIS, MN 55408
(Contact J (Phone)
APPLICANT SIGNATURE yth....--- DATE £ (l of t j
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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
0
Fctin f c $
TOO.— Building Permit #
The Minnesota Statutes § 32613.148 �
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $
year effective STATE SURCHARGE $ .500
July i, 2010, until June 30, 2011. TOTAL PERMIT FEE $ sf' ` �
The minimum surcharge fora "fixed fee" permit
is , beginning July 1, 2010
tits Appncatton Becomes Your Building Permit When Approved Paid . J -- 6 Recel o. 6333‘v
Date i t. T / By
•
Building Official Date 1 /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372