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O� V RIO,p Date Rec'd '
ft. 0 CITY OF PRIOR LAKE PLUMBING PERMIT
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z. avid city PERMIT NO. 1 1 I ( q
(Please type or print and sitE at bottom) 3. Yellow Applicant
ADDRESS
ZONING (office use)
3155 17r1aJ ?I vi C trc t(
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( kti (Phone)
' L14 D-57 Li`l
(Address) 3 755 t_s,i14v ( t/ `
APPLICANT /�,r1 6�` II�� �j
(Name TD S (j ail -r..- (Phone) '�-�`1 -2 ¢ 21 Z 7 (Address) 2 - C 1 0 ( • 1a . `- I,k �. ( III, ��53 3
(Address) /Y /,, / // (City) (Zip Code)
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(Contact Person) (Phone) /62 1 - , /.3�J'- /L/ L
APPLICANT SIGNATURE I. ,;� DATE 1111 .
APPLICANT PLEASE COMPLETE BELOW
Quantity ' Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Roush -ins
Dishwasher g 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 i
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 ast $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ _ I p i - SD
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5:cro 5
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE 5'-i-.1)
is $5, beginning July 1, 2010 $
This Application Becomes Your Building Permit When Approved Paid is p Rec !t No to 7/53
Date By
Building Official Date 3. Z � . I /
1
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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