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Plop Date Rec'd
,t CITY OF PRIOR LAKE PLUMBING PERMIT
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sly File PERMIT NO. / / • 3 ?
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3. Yellow Applicam
• ase J. or . • and rd." at bottom
ADDRESS , I ♦ 7 'AL. ZONING (orrice use)
ti ute jOOL—
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(N WNER 1 5D 11 1 �� �`' � . 't Sri' Ck a ) ) (..k C: "e�1 (Pho -
(Address) f &(o Ci .: }'! - i i `l . >r ,
APPLICANT ( j 1
(Name) Ill E r R(r Th cJ t - I (\i (,,^ y / l � L (Phone) t ' f r� " 7 } ! S l�
(Address) �� 0 C K�t ( K« Moo( l� ( I 1 ` j�
(Address) (City) (Zip Code)
(Contact Person) - ..41■ ' _ _ / r (Phone)
APPLICANT SIGNATURE AEI DATE J / /
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APPLICANT PLEASE COMPLETE BELOW (Pz Lx.L lrt
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 (I 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 t�
year effective PLUMBING PERMIT FEE $ .
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ S•GC
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 5-41.c-6
is N, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 3 — A ✓ 6 ---o Recei t No. b7
Bandies Official Date Date J r- ` � ` ' � 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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