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°l , . - ` CITY OF PRIOR LAKE PLUMBING PERMIT
3 11. 12_,
4t ti'NEse I. Blue File
2. Gold City PERMIT NO. sz
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
ILlo5c9 NM l i 2, ka • E.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name)
OWNER �C71(�l S f I CXA.A (Phone) / L c/ D �
(Address) I 0Sb OCa Q.CX Pry'
t r l.CAAL,_
APPLICANT •
(Name) � 1n'( e.,.. Pt vY-� � v - e Cc" In (Phone) QS t iN.- Wy---t
w �� 9
(Address) 1 4X to, SA0h7p_e_e 5
(Address) �, (City) (� r , ( (Zip Code)
p
(Contact Person) P`' t� ' D« / l i/►' r ' �x( (Phone) Q "/ �� / yL,''l
APPLICANT SIGNATURE -___,'"/ DATE / "id-
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher l 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 I% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes $ 32613.148 tst ila -� Building Permit #
"SURCHARGE" has been changed for one Lig SO
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ — 5106. — ) --- N .
t 00 ' O
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ y • Sro
is 5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid '7/ .CE) Recei o. /� , fg 77
Date /. / 7_ 1 2—
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