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Plllp Date Rec'd
°r b, CITY OF PRIOR LAKE PLUMBING PERMIT
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PERMIT NO. /
3. Y . Yelll av Applicant lly J . f�j}
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(Please type or print and sign at bottom)
ADDRESS 1 i OA KS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID •
(Na R 1 i1- 1 1 .0(6` O1. h �� i.() ! 'eC i:�( .J(.°�' C �1( o�) i r CC F ..> a 1
( A d d r e s s ) / `- I Cl -E. S )'1 . - i a) — C 1. _SGT - ,
APPLICANT
(Name) -1 (Phone) (el r) ' ,:td-)- 6 0 S — / ],
(Address) 3I ;' (k (V Coo:: �d rTC oc e l eti I ' K . 17
(Address) (City) (Zip Code)
(Contact Person) r�1/4 ` , _ A (Phone) (.,N , j-
APPLICANT SIGNATURE AIM DATE .457? -11
APPLICANT PLEASE COMPLETE BELOW (Rio'' LX. t,kci)
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 1% of job cost with a $49.50 minimum Residential, New One & Two-Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 Est $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010. until June 30, 2011. STATE SURCHARGE $ S.CC, :)a
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 1 4,c6
is , beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 5 - A 6 - 0 Recei t No. b7
BuiWlns Official Date Date Jg — Y / 7/ B
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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