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PRZO Date Rec'd
- CITY OF PRIOR LAKE PLUMBING PERMIT
� ! i e i
Ih'NEsoo t. Blue File g 2. Gold Ciiy PERMIT NO. i _ y
3. Ycllow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
Si C 1 IA ) a 1 G1' r tc L \ M -1A) .
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION - PID
(Name)
OWNER f'1 L) i11e - (Phone) "1SZ D✓-./" L+-1%9
(Address) 1 ,/ L'1 l 11jt -a r i L La ii N.O.
(Name) ANT 1� f (Ile ( )nat.\ I C' k (Phone) 1113- Co (62-- � �,� ✓, C l 0
(Address) ZS 1 r_..—_,-,, c�� - t1 )C ) Gt . ' i e - - DO - fa nn ks . , 1 . (Address) (City) (Zip Code)
(Contact Person) inn rn In / I L l�Ct 1-_, (Phone) 17 / 1 CV) - 43
APPLICANT SIGNATURE /� " - ' /'/ DATE V1., ' oLP ` (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 (I or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink i 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 $ _ rihi lding Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is Si, beginning duly 1, 2010
This Application Becomes Your Building Permit When Approved Paid s / 7 (� J 2) Receipt No. y t 7 �✓ [/ `
Date y / i � /� By � i
Banding Official Date / 7 {
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372