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O. vRIO, Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT 3 Z I. ( I
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41:1n'NESDc'' Blue File
2. Gold City PERMIT NO. (( ( -7 a
3. Yellow Applicant /
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 59 Freni a- A-,,_ Nv\/
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER e / t. ,. te i I S C I ✓`U /� -7 (i,13
(Name) U Lcu'� —i" (Ph one) "15 Z- �� / 2
(Address) 15T7 J FreinG /` l A f v V \
APPLICANT A q aivn.tcps (Name) l l GU,) c_t_ (Phone) g 420'3
(Address) I 13 1311th l Ow-IL - 55
(Address) (City) II�� (Zip
(Contact Person) ca/�1 e- j 1 (Phone) 616 "rte t s \
APPLICANT SIGNATURE ' (... _____ /[ �c %� DATE 1 7)
0 • 1
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
ost $ Building Permit #
The Minnesota Statutes § 326B.148
SURCHARGE has been changed for one PLUMBING PERMIT FEE $ 51 tJD
year effective STATE SURCHARGE $ .50
July 1, 2010, until il Juune 30, 2011. �
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ J4
is S5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 i C/ l� rn Rec t No. / Z is?
Date
Building Official Date � 1 1
2 B
,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372