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°, , - 1 y C ITY OF PRIOR LAKE PLUMBING PERMIT
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1. BIM File
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2. cots City PERMIT NO. � _ 70
3. Yellow Applicant
(Please type or print and sign at bottom) Corr ADDRESS 1 { CpA 'a 5 h--I, c ' F iv c ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) J1n nrrAil0 neit ( Phone)JV-c) FMS - S 7
(Address) 1 C 6a-q Co riCi&. L{\.) N €--
APPLIC � Pt {� ) r
(Name) I r+ n Y 3 '.5'.: Y S Y y'} 1 4
�l J � C''i�ll (Phone)
(Address) 1 90 w . 3 144 Q.A.t� (Le __A_ SS'' ) 9
(Address) (City) [ (Zip Code)
(Contact Person) 0 _ A. I /. (OX 4 (r 7
f r (Phone) 4r) `'� 4� 9
APPLICANT SIGNATURE P / i' / � ..r. ` DATE ) — aee C=1Df
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 I% of job cost with a $4930 minimum Residential, New One & Two- Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.145 ..)st $ / I 0. Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 4 44 St)
July 1, 2010. until June 30, 2011. STATE SURCHARGE $ - ' t 1}17 313
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 54 •
is g., beginning July 1, 2010
1
This Application Becomes Your Building Permit When Approved Paid J ,/ s� Receip N . 6, 6
Date j 3 G ( z_ By
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372