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A a, CITY OF PRIOR LAKE PLUMBING PERMIT
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JVNESO
1. Gold File PERMIT NO . l p
2. Y Airy /1
3. Yellow Applicant (J l7
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
•
41)1 8' i brat 1 . r ,
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) /1111 i G, e j . (Phone)
(Address) 1 L+1 / FLU G Mi rd 11-2-. N �� riPr L.-- - 1 WIN( Gs 372_
APPLICANT y • L 1
(Name) bet 1 4 - " - Tr - ' the n t f (Phone) 61S 2-- el S 5 ' `7 3
(Address) 174-04 6e 061 / et-r. a /d L A c-)Ae% II e) MI/ 50 44
(Address) (City) (Zip Code)
(Contact Person) JO 1 14-11 ii_ (Phone) 1'51- 1 y(v4 3
APPLICANT SIGNAT • All 4 _ - _AIAL . _ DATE 8 i 1 / l 3
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain 1 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
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 § 32613.148 Est $ Building Permit #
"SURCHARGE" has been changed for one A � 5d
year effective PLUMBING PERMIT FEE $ T
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ -5 -. Go
ism, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid i / o Receipt No. 4 9 79
e By
Building Official Date Date // i ,,,,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372