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04 ?Itto Date Rec'd
-, CITY OF PRIOR LAKE PLUMBING PERMIT
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1 NNSSO�� i. Blue File
2. Gold City PERMIT NO . I--7 3. Yellow Applicant 6 l
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1
Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/8' ac/r2-,,,-;- (6r6 #4/4_1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) C 4yDI'7ij 1 -S% 0r4, (Phone)
(Address)
APPLICANT i
(Name) ( 2 94z. Cot' '�,;-- GG c (Phone) -.7 6 S06Q
(Address) /72 /fj jr C- (City) Zi
(Address) ( ty) ( p Code)
(Contact Person) . eA• _ "!. ■' _ . (Phone)
�, �� DATE �" /4 - /... 2 . , APPLICANT SIGNATURE
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 compai lucent 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
' "- st $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ 11-)
until June 30, 2013, STATE SURCHARGE $ 17. K.?.50
The minimum surcharge for a TOTAL PERMIT FEE $ J zJ
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid_ . --,) / Rec , o. / U9/
Data' / y; ,, By
Building Official Date T
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372