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4 CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue City PERMIT NO. e-, 0 130
2. Gold City 1� � 3 i
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS � , ,, ZONING (office use)
5k "" 4 LI/ u 0-lf br
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( O Na WNER A 1 �' (Phone) " 1 5 - - "i 1 . J ll
(Address) 5� LAA Ar V
APPLICANT 1
(Name) W, (Phone) () 6D -
. , 1 AA! h ...a ^ ���.
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(Address) 95-XD 1 l SS S°)
(, N dress) (City) (Zip Code)
p� `` try 1
(Contact Person) \\ ' .L: 2 R�. - 1 Wi1A ` (Phone) q L� ,�� ` t l - ` o I v
e' y
APPLICANT SIGNAT • ,...,-.._It_ 0! JA i k A AA DATE 011
II
APPL CANT 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 Lawn Sprinkler
Water Closet (Toilet) Other pi i , on ksnfyhnq-t(
otao 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 $ i / Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ L iq5D
year effective STATE SURCHARGE $ 6761) ,
July 1, 2010, until June 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is $5, beginning July 1, 2010
This Ap 1 a • Becomes Your Building Permit hen pproved PaidA r U Re �t No. 6 ( 3 G 0
`
I (o Date
Building Official ate 9 / 7 ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372