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Date Rec'd
4 5, r c
i CITY OF PRIOR LAKE PLUMBING PERMIT
i~to
4 ttNrv>rse I. Blue File NO. ......0792_
2. Cold City PERMIT NO / 3
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
N
IDOL h t 1 k. 'A vt, St
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID •
( O WNER I PD l 1 ( Phone ) 0 7 i L
(Address) 1 l!1 +S `"1 Fi `l al`s """'-Q. v L 1
(Narne) SDT� vTh f'7e )(�` (Phone) q' �1 � (- ` 1 4
Address 6o w. 3 to C ) � -- J 5n�� p-LA, v6� e, I
(Address) V (Address) (City) 1 (Zip Code)
(Contact Person) S A 1i`U l ei ) P&i\ S (Phone) -/ U S — L i k l `]
APPLICANT SIGNATURE DATE - 1 — I r k - ) 3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough - ins
Dishwasher ( Water Heater (etre 16 [e
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
1 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
a'..k Residential, Additions & Alterations $49.50
The Minnesota Statutes § 32613.148
• "' Est $ - :J V Building Permit #
"SURCHARGE" has been changed for one
y ear effective PLUMBING PERMIT FEE $ .
year
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ C1 L •
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ p,
is 5.5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid 3 Receipt No. f i i 3 -
Date
By �
Building Official Date 1/ 3//
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372