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PRI Date Rec'd
4 CITY OF PRIOR LAKE PLUMBING PERMIT
U Marcus Werner
3420 Spring Glen Circle Nw
4IANESD�P Prior Lake, MN 55372 1. Blue File PERMIT NO /10z�
9524408512 2. Gold city / VV
3. Yellow Applicant /
(Please type or print and sign at bottom;
ADDRESS ^ , ZONING (office use)
31+21) Sr
P g&i y en Ci r r I v
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N rw rcu ` S v LJ1 V' (Phone) ( 6 152) • 8512-
(Address) 3 6,p r I a Ei 104 C r N " '
APPLICANT
(Name) NORBLOM PLUMBING CO. (Phone)
(Address) (. -4033
2 °V ' r t)1RFIELD AVE. SO. (City) (Zip Code)
(Contact Person) MINNEAPOLIS, MN 55408 (Phone)
APPLICANT SIGNATURE DATE ijieji 1
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
0
The Minnesota Statutes § 326B.148 Est $ O , Building Permit #
"SURCHARGE" has been changed for one i /f? SD
year effective PLUMBING PERMIT FEE $ 7"1
July 1, 2010, until June 30, 2011. STATE SURCHARGE $
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 54,6-9-
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid � � / c o Re 1pt No. / t.c r
Date
Buildine Official Date / // ,/ i
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372