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°- o { CITY OF PRIOR LAKE PLUMBING PERMIT
4
,. Glue File
2. Cold City PERMIT NO. 12- b 53
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
. 9 \ b �l�C 'P 6 t. S
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER 6 C o W S��.,ku_.,v -t.
(Name) (Phone) C4 52 "' � 4- 1 E: , �...i 1p a c _,.
(Address) 5b ( 0 P c '.` ' 0 61,.... k, W> --
APPLICANT -
(Name)- - 116 elt f 0 1 O c C Y " \ . • C. et. \ (Phone) - I ? • 7 1 00
(Y 2
(Address) U' l i 01 j v4 C °' ;' , ,-'' 4 77 ell
(Address 16 (Ci �, � (Zip Code)
(Contact Person) . UX tid (Phone) + ` '7?' - 2 - - Ibb
APPLICANT SIGNATURE '" T'�`` DA'Z'E I IL
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 x 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.148 '1st $ Do Building Permit #
"SURCHARGE"
effective has been changed for one
year PLUMBING PERMIT FEE $ ,
ye
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ Gj 4.
is 55, beginning July I, 2010
This Application Becomes Your Building Permit When Approved Paid 94 R ipt No. lQ (42
Date W (/ 1
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