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°.brd _tiic CITY OF PRIOR LAKE PLUMBING PERMIT
4112 VNESO ° 1. slue File PERMIT NO. /` /�
2. Gold Cit i�f t 5/ V'
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
RiI)$ kt11I✓Lk-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER R .o,'i Lrl lc k s 1'v10.ex (Phone) 6 '4;4. 2 - 1 /gi7 -"l l ! 1
(Address) lulls 1a / U ✓ k a _ pi. e r i o r 1 4 A 0 L 1 1
APPLICANT
(Name) (Phone) C t e — Lilp Q - 83 1.4, (
Appliance Installers of MN, Inc.
(Address) 11105 R t ers St. NE (Zip Code)
Prior Lae, 55372 (City) ,, // ('p
(Contact Person) t _A
II __ (Phone) CM— LT bq - g �-�"7" jez ,lia
APPLICANT SIGNATURE t _' % / LI v DATE
Al
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tab 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 § 326B.148
- ist $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 54. co
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 5 q.
is. beginning July. 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 + , f i pt Nd. 3 2_2_
Building Official Date Date ( + =( — B
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372