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-- Date Reed ` CITY OF PRIOR LAKE PLUMBING PERMIT
F
1. Blue File I
2. Gold City PERMIT NO _1�.�,3
3. Yellow Applicant (/
(Please type or print and sign at bottom)
ADDRESS S S S4 t9�4� l ,'tom 1 \ ZONING (office use)
J QUO
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID •
(Name)
hA 1 l 1 SSA ,4" k (2X+ I \ (Phone) / �( — Y L1 t4i 3
(Address) I L, I 4 CGS 10k W 1J LL)
J
(Name) r Lo lh � t 4 04- (Phone) �� 7 S t)9-14
(Address) ) 3 Rd "e Lhx1 sai ' ci
(Address) p )6\11n1 (City) (Zip Code)
(Contact Person) 14n --IL 1A.,11lN b i (Phone) / '0� 9 yj/
APPLICANT SIGNATURE DATE
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, (f Additions & Alterations $49.50
The Minnesota Statutes § 32(113.148 — 1st $ IbOC) Building Permit # / F 0/4 3
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ -5))
.July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5, Qv. �9'
The minimum surcharge for x 'fixed fee" permit TOTAL PERMIT FEE $ ,SY •n
is , $, beginning July 1, 2010
This A lication Becomes Your Building Permit When Approved Paid K Receipt No,
L
-t$
/ (—/ I Date By /�j
B uilding Official Date 11-0 -1 /k` y 4 ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372