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PRI Date Recd
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CITY OF PRIOR LAKE PLUMBING PERMIT
4'1VNESO
1. Blue File
2. cola city PERMIT NO. 1/ 27
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS Eff,_ ZONING (office use)
/-4/ -4//0 / it/ Ge
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER � ��
(Name) 6/4_4/ Gi /) i'.5 (Phone) c /oZ 'V /y ' (Address) 3 i . 4 - ysi t
APPLICANT / "
(Name) I3e 1 f‘ Ai , C::2 7 , (Phone) � C /o 6 7c" a 3 der
AI. (Address) OP. - S/. j/ 3 a - A- �,� S /: - 5 -- i i :
(Address) (City) (Zip Code)
(Contact Person) ■...1,) 6, c.c. T (Phone) G' l 6k ' 4e 7d oZ 3 co
APPLICANT SIGNATU • - -41 Air DATE -- a 3 — i/
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 V 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
r "ost $ Building Permit #
The Minnesota Statutes § 326B.148 �]
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ iti- J V
year effective STATE SURCHARGE $ 5 - (/[.3
July 1, 20 Jun" 2011. TOTAL PERMIT FEE $ Sy. b
The minimum surcharge arge rge "fixed fora "xed fee" " permit
is 55, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved 4
Paid - ` {v Receip No. ( ?, r
Date/ . ` j � / / BY
Buildine Official Date lQ d'-� l
•
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372