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R Date Rec'd
° CITY OF PRIOR LAKE PLUMBING PERMIT
F
Q
jnNESV� P 1. Blue File
2. Gold City PERMIT NO. ti , / 1 Q�,
3. Yellow Applicant �-�+'
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
H 111 S\ANcidtj - r av I
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT (7CVlt (Name) ' (A 1 (Phone) q'- LL [ 1
(Address) ) I - l; � ' " d � o I K ! I o 1i 5S1
1 A S t ( Addy• .) (City) (Zip Code)
(Contact Person) t //LAO f 4 (Phone) " 1 S t -- WO
APPLICANT SIGNATURE ' �� r , ,L' /JlV DATE � f (s
NI
I� /
APPLICANT PLEASE COM '4 ' E 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
Z. 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 ^lst $ LI " t 6D Building Permit #
"SURCHARGE" has been extended PLUMBING PERMIT FEE $ L9.5D
until June 30, 2013, STATE SURCHARGE $ 5 ci) ` '""
The minimum surcharge for a �
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ �3'1_
This Application Becomes Your Building Permit When Approved Paid n / f J� Receipt N �5 7
J `T
Date a / L ' , By
Building Official Date lJ •
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372