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CITY OF PRIOR LAKE PLUMBING PERMIT C.. Date Rec'd
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1. Blue File PERMIT NO./a., 67
2. Yel App ✓
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
. 3qa. Spr,nn Glen C..A 13. -
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name) (L) r A ( v &r Q l (Phone) — t 5Q " H q 1- C6 `13
(Address) 3 `, q a "p n y CD 6{il \ Nr• N AA) or L& 1 553 r7 c�
APPLICANT , (�� r L] _ u�
(Name) p k lance 0 Me61 -T-nC (Phone) "1 c @-� _` t4S
(Address) 1 r3 Dan - Va.. C..,1:(c/1 Shake 553'19
(Address) (City) (Zip Code)
(Contact Person) 3 arn 1 e c6 p 0 (Phone)
APPLICANT SIGNATURE DATE l —12J
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
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
The Minnesota Statutes § 326B.148 :ost $ ,.01) Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ .50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 5
This Application Becomes Your Building Permit When Approved Paid �if 0 Rec i t NQ.,/. / _
Date (. Z3 ` - L 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