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gre CITY OF PRIOR LAKE PLUMBING PERMIT
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Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
_5 OA ( b 1 tvit, er,A,4 i
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PIO
OWNER --1— r 1
(Name) L -1--f" KlA (',ls.. Gt. G, 1 4 -, �,P -_, (Phone) (Z• '11-1- 27-s y -
(Address) 3%1.4 Cpl . 1° --- )1I. /r\ 0_ .
APPLICANT (Name) 5 MIL ANC �� I414110 lvi- ° l - 1--)"W kb (phone) 1&.5- Z?� 1
(Address) \S53S
,/� hone 1/� .✓) M t bu 4 -01 wVl4'1 ✓' ` Li L/ 7
(Address) C ity) (Zip Code)
(Contact Person) dl/t/ ti' (Phone) 1105" 2-7- I - 4 Y
APPLICANT SIGNATURE . • I .►1 _. , , . I if DATE K - Z I - 2 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 J 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 st $ _ Building Permit # _
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ 4 0 . S G .
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ •n r) - :5ti
The minimum surcharge fora "fixed fee" permit a TOTAL PERMIT FEE $ 5`j
is S, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid ; , CV ReceipVN • (�' ?
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Date By /
Building Official Date "'. ` L- 1 ,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372