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BRIO Date Rec'd
2 R ? CITY OF PRIOR LAKE PLUMBING PERMIT
7.3 t 1 44
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.„.„. ....
4iiNNE.soo I. Blue File PERMIT NO
2. Gold City // , 004,Z
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS i ZONING (office use)
6 1p 0 V J't S -1-1.,0,,r-1 Ave_ S vU
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) � -eiln (1G 1--0 U—€). a,(y (Phone) c 1 s - 0 L- I a I 1
(Address) 1 LD l LD b We-5-1.1)..__. A\.2_ S ud
APPLICANT T P l vr,s 1 1 I .. (Phone) g ra— 911 111-/ V
(Name) $l �C
y.2v t3 . r
(Address) 1 553)c)
` � � U —
(Address) (City) (Zip Code)
(Contact Person) S‘"11 woff (Phone) qic)-- y V `t L1 't
APPLICANT SIGNATURE DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 Water Heater I2ep 1 a. C__e
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
- ' ' " )st $ q00 - Building Permit #
The Minnesota Statutes § 326
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 4 9
year
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ S. 00
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ .Sy •5
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 54 .. Receip No6 !&
Date 1 Z f / ( By.
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