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A, n � CITY OF PRIOR LAKE PLUMBING PERMIT
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I. sol File
2. l
PERMIT NO
Yellow Applicant
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3. Yellppliconl
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
I `- f — 1 a-s Ter o -4-e `tea.; I N -
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
O WNER `r 1 6' I e ��l (Phone) q `i Lo Moo
(Address) f ( 41) - g - T rb - C,ta ` 1�ra�1 I NE
APPLICANT
(Name) 0 P vrn t St S 177 "t l (Phone) % ? y J L/ 1 / L/
. � Q �� ?') i
(Address) � � (>1' 1�I� --'�•�
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(Address) l g - (City) l (Zip Code)
(Contact Person) 1 t G S V of i 1 Pi • ( 4 -1 1 45 — Ljc2j L7
APPLICANT SIGNATURE — DATE 3 —/ 2
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 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 T hst $ / - b Building Permit #
"SURCHARGE" has been changed for one y ( ,
year effective PLUMBING PERMIT FEE $
July 1, 2010, until :lune 30, 2011. STATE SURCHARGE $ S.60 it
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 6-9.
is, beginning July 1., 2010
This Application Becomes Your Building Permit When Approved Paid g Receipt No. i 7 /
1 , , s70 9 1.._
Building Official Date Date .6 /3j /2-- By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372