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YRip l_/' Date Rec'd
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to CITY OF PRIOR LAKE PLUMBING PERMIT
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" x MarkGaughran
15201 Oak Ridge Circle Se
411 NNEs o ` 0 A Prior Lake, MN 55372 ,. awe File
9524475098 a. vei oW City
PERMIT NO. G�c`�
(Please type or print and sign at b C/
ADDRESS ( 2.,0 1 ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( O INa WNE R /1 rl 6 a4 , h I ran V (Phone) c» L/7 G ! O
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(Address) n2 1 11 O.' 2� �' % - rat) S
APPLICANT
(Name) NORBLOM PLUMBING CO. (Phone)
(Address) (612) 827 -4033
290 &'@QRFIELD AVE. SO. (City) (Zip Code)
Ara
MINNEAPOLIS MN 55408 ( Phone)
(Contact P rson) �}
APPLICANT SIGNATURE °�_ DATE �!
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
Estimated Cost $ (RD . - Building Permit #
PLUMBING PERMIT FEE $ 461 . 52
STATE SURCHARGE $ OS*
TOTAL PERMIT FEE $ G'�j✓
(Office Use Only)
1
This Application Becomes Your Building Permit When Approved Paids J�v Rec • f (� o. / (4v
Date 7 By
Building Official Date 9 ' ` 7 � gyp ,Ii /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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