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from:Genz -Ryan 952 767 1900 05/31/2013 08:07 #341 P.003 /0:r,
0 P Itto Date Recd
y CITY OF PRIOR LAKE PLUMBING PERMIT
"' 1. Blue File
2 aoia coy PERMIT NO. /3
i. Yellow Applicant
(Pleas type or print and sign at bottom) " ADDRESS ZONING (Duke use)
15 I � la-v\o,.. V I-eaw (J. _____
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER , a C�
(Name) n �1- -,16� -1 lU �t X^ j .Y\ (Phone)
(Address) Ai __ _._. _ — ---
APPLICAN" C ~
(Name) tt OA C ` C(/VA Y (Phone) y q - �
1 ( 63 1
l r i
(Address) _ • At I t 4 3 �(,,Yr�i (�. ��°) s-A ( 1 S$?j3
(Address) V (City) (Zip Code)
11
(Contact Person) C ( �} a (Phone) `1 s a -go-) ,
APPLICANT SIGNATURE 1 XL li L DATE 6 30/ / J
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
1 - Bath Tub with or without shower Rough - ins
/ Dishwasher Water Heater
_ Floor Drain Water Softener__
a _ Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
1 Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
a Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family 1% of job cost with a $49.50 minimum Residential, New One & Two- Family S 149.50
2 / r� Residential, Additions & Alterations 549.50
The Minnesota Statutes * 320
20..14*i — tat $ J ) .! v Buildin Perm t il'
"SURCHARGE" hose been changed fide one -
year effective PLUMBING PERMIT FEE $ t
July 1, 2010. until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $
is , beginning July 1,1010 ` &
This Application : , rites Your Building Permit When Approved . 2 1 b„),,, t _ Receipt No. • / �]�
G-112, i 1 By 1 tlf!
$..s 1 7. i Date �.k.:
24 hour notice for all inspections (952) 441-9850, fa 52) 447 - 4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55312