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V Rip Date Rec'd
" -14 44 CITY OF PRIOR LAKE PLUMBING PERMIT
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(Please type or print and sign at bottom)
ADDRESS 0 ZONING (office use)
411 NikAl d ej t Ski SE
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) (Phone)
(Address)
APPLICANT ,,
(Name) a l ,_ 1 1 1 i � l , V (Phone) `I 3 Z- 13 " 3 Li d
(Address) k S iJ C O A1ti. Y.� �. ULL 1�' i ttok 4 �' k si //
(Address ) t (City) (Zip Code)
C I _
(Contact Person) (Phone) (S t 2.-1 (4 1 - 03 5
APPLICANT SIGNATURE ci °- C& ' 1-A L,d a AA/kJ `f'� DATE 1 "5 - 2-0 2-
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 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 by f
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family I% of job cost with a $49.50 minimum Residential, New One & Two- Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326 w Est $ Building Permit #
"SURCFIARGE" has been changed for one
year effective PLUMBING PERMIT FEB $ 9 5 0
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 5 0 C :60-
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ )4 b 0
is 55, beginning July. 1, 2010
This Application Becomes Your Building Permit When Approved Paid 0 - 34 v D Re No. e - ( . 34 , 2 _
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Date r� //,/ By ri
13aildinL Official Date / r � ,. ,,.
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372