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( .(pRiP Date Rec'd
' C ITY OF PRIOR LAKE PLUMBING PERMIT g 1 Z . 10
, 'x Tor Hansen
3529 Island View Circle Nw
INxESO�� Prior Lake, MN 55372 I. Blue File
9524470607 2. Gold city PERMIT NO. /0 67
3. Yellow Applicant
(Please type or print and sign at t
ADDRESS '
a 5 / 1 aid V t• e vV C rck ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 'Fur Y Li ( (_152 ) '44 7 D�O7
(Name) V Phone
(Address) .5W`1 ,Lstict.rot 1f c e, ✓ V C i afi V V
APPLICANT NORBLOM PLUMBING CO. (Name) (Phone)
(012) 827 -4033
(Address) 2905 (( ����(��1ELD AVE. SO.
�((A.�`d�eSx) (City) (Zip Code)
MINNEAPOLIS, MN 55408
(Contact Person) (Phone)
APPLICANT SIGNATURE ;/ DATE g WI/2
r
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
i 5°
Estimated Cost $ . - Building Permit #
PLUMBING PERMIT FEE $ ''T—I. 9°
STATE SURCHARGE $ °`
TOTAL PERMIT FEE $ 50
(Office Use Only)
I
This Application Becomes Your Building Permit When Approved Paid 54_ � Re' • ipt No. (a t o 9
t71�
Date gy p, b
Buildine Official Date 'V `� `
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 0 '
4646 Dakota Street S.E., Prior Lake, Minnesota 55372