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1 Date Rec'd
°6 e CITY OF PRIOR LAKE PLUMBING PERMIT
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2. Gold Glad City NO . / j f -
2. Airy / J
(Please 3. Yellow Applicant
( type or print and sign at bottom)
ADDRESS ZONING (office use)
1 1 0v14'r 6
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name t_ t .t, 11-0114N hick (Phone)
(Address) 311 0 1AAN\ 4n/ Nat,
APPLICA� ( �
(Name) 1 C) Y l' } /� M— �-� .,(� 1 � (Phone) /Lob - ZS J (/
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(Address) l55 J -e �1 J Phi vIA n1j'►' \ Min 55 i
(Address) (City) (Zip Code)
(Contact Person) '' f / `1 (Phone) ! Le) z-GJ *5 - +7 If V
APPLICANT SIGNATURE -W t,1 CiA. (,,(A4t- ' DATE 1 "'( - 2-0 1 Z
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 _ _ 1 Lawn Sprinkler
Water Closet (Toilet) 1 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 '1st $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ - q -50
.luty 1, 2010, until :lune 30, 201 I. STATE SURCHARGE $ 5000 -5a
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ nii .50
is 55, beginning Judy 1, 2010
This Application Becomes Your Building Permit When Approved Paid Receipt . No. i
Buildine Official Date Date ,.r/ OP 2. By /� k !� ./,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 (/
4646 Dakota Street S.E., Prior Lake, Minnesota 55372 I�