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CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2. Gold City PERMIT NO. 16,_ 0A
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 laM LV b 1 1 , 5 SE—
LEGAL DESCRIPTION (office use only) ,
LOT BLOCK ADDITION PID
(Na e �1 Cry-AA-IA,' �� (Phone) O - t
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(Address) SCA, J ' 1\ 0\ LIA)6 t 1 MN 5 6 S la
APPLICANT /'�,
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(Name) v Y 1 I U DI V amp L (Phone) (4 \ ��� ' `k
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(Address) 301, 0 E O W 1261. . � 15' ii.A 1 r 1 N 5'
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(Address) City) (Zip Code)
(Contact Person) J (Phone)
APPLICANT SIGNATURE DATE o ( 3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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
st $ Building Permit #
The Minnesota Statutes § 326B.148 �}
"SURCI- LARGE" has been changed for one PLUMBING PERMIT FEE $ vl a e 9Cf
C
year effective STATE SURCHARGE $ 5 . ()Q .SE
July 1, 2010, until ,Tune 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 5 L . 0
is, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved ii 6` - Receipt Not
` By
Building Official Date tam l ! 3
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372