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C) `'' CITY OF PRIOR LAKE PLUMBING PERMIT
U 1 A
Sl ikpiESO' CA 1. Blue File
2. Gold City PERMIT NO. /2, 0
3. Yellow Applicant GG//
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
53 7$ - )r/ fv (.5 hDre 72A i) $
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 1-6 ( 77 e ye ns 6 2-363- bvbg
(Name) l7 (Phone) 12
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/-2., r v' or-e S i ies i / s
(Address) 0 X T f�
APPLICANT 1" t ce/A P' n; i Cf� l co 95-2,--7s-s-
(phone) �f� /�
(Name) �Q � .L.�
(Address) (4 0 t ' <4._ A/ GG, A)e} / 5 U 5‘o 7/
(Address) (City) (Zip Code)
DAV l 0 S -r,✓ f lePt (Phone) ( / 2 -
(Contact Person) /�
APPLICANT SIGNATURE ���� �x lac= i �� DATE J4::� '/A/
l:
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
Dishwasher 1 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 ¢ 32613.148
" )st $ Building Permit #
"SURCHARGE"
effective has been changed for one P LUMBING PERMIT FEE $ 47.--
ye J
July 1, 2010, until l June 30, 2011. STATE SURCHARGE $6 _0() /btr
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 54, 6
is * 5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid ei, s7) Recei No. ; / C� ,f, C/
Date f Z By U7 `t f
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