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4.,, -� ; . , � CITY OF PRIOR LAKE PLUMBING PERMIT
ArtiESO 1. Blue File PERMIT NO . /�
2. Gok City / / . /ZO(
3. Yell'w Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
■.D 7 - a D o e..,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER = ._.
(Name) F. t'l ( \0. rl F_ L Nk. v S C.) e Sl (Phone) 9b - Ii-m /f , 3
(Address) L9 `73 Q Ai.„1.-1--.., / C `Koa d 5 r 'Pc- t L c:`--k e_-'
APPLICANT
(Name) Nrx -i- k e. t` k LL b i ti (Pho e) 7 . 3" - ","5 - (9, - Ka a &'
//�� N.N) 5
(Address} 7 C� n � rte, / � J � t v� � � !
(Address) (Ci ) (Zip Code)
(Contact Person) Me 1 es < C S (Pho ) 7(0 ✓- a a ? - 37 0 /
APPLICANT SIGNATURE 61-1.6-11-0 KM DATE / 0 a O— ii
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 Re idential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
- - ' " hst $ Building Pern*t #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ y q 60
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5 •60
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 6 CI . 5 0
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid c[ f S v Rec No. 6 ,7 t
Date � (I_ ` ( By
iidin
Bua Official Date ! T -
24 hour notice for all inspections (952) 447 -9850, fa (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372