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(.47 Rto Date Rec'd
CITY OF PRIOR LAKE PLUMBING PERMIT
H i x 0 r 1_ ll
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NvivESO'sP
2 . Bice File Gold City l
2. PERMIT NO / 0044,
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
530L peer F►ekd LG Sc.,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
Naam) V1 a.'ti ! A C‘t r (Phone) C I 5Q- `1qO - 3339
(Address) (p G c1 e \U SE PC ■Gf take
APPLICANT
(Name)
'` (Phone)
App : 7,tions Inc
(Address) ,, i a
c r . (Address) (City) (Zip Code)
55379
(Contact Person) aln �e RI Ppa (Phone) q53- - 9o3
APPLICANT SIGNATURE � i . d _ Ili . _ � _ • • 0 DATE ��� " 1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower t 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
The Minnesota Statutes § 326B.14 'ost $ Building Permit #
•
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ t-lq`SO _ 0
The minimum surcharge for a STATE SURCHARGE $
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 544444 5 g ft,
This Application Becomes Your Building Permit When Approved Paid SV Receipt No. 6.3q(3
t �j By 4 0/
BuildinE Official Date Da ted ._ - B
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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