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° CITY OF PRIOR LAKE PLUMBING PERMIT
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4'NNEsc, t. Blue Pile
2. Cold City PERMIT NO. 1 Z , 570 "I (�
3. Yellow Applicant
(Please type or print and sign at bottom) r
ADDRESS t ��iM k ?.- ZONING (office use)
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LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICAN n \o& pitonloi, 1, / � (Name) �) IA�II' J i-�"Q -�'1 �l- (Phone " ) n "I JZ' $
dress BOO mei, J uu 5 ij
(Add s) (City) (Zip Code)
(Contact Person) (Phone) 40 11 141 5 3.J
APPLICANT SIGNATURE -1 i DATE 5` 2 -D - 2- 0 / 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 1 Lawn Sprinkler
Water Closet (Toilet) +' Other
FEE SCHEDULE
Industrial, Commercial & Multi - family I% of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
,l �� Residential, Additions & Alterations $49.50
`" $ ` 47) •DU Building Permit #
The Minnesota Statutes $ 326B•I48
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 4V
! 5O
July I, 2010, until June 30, 2011. STATE SURCHARGE $ 5.D 0 :5
The minimum surcharge fora "fixed fee" permit TOTAL PER1VIIT FEE $ :
is 55, beginning July. 1, 2010
This Application Becomes Your Building Permit When Approved Paid L5 - 2 /: S - Re'l No. 660 0
Date , / Z B
Building Official Date 7 .
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 ,
4646 Dakota Street S.E., Prior Lake, Minnesota 55372