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CITY OF PRIOR LAKE PLUMBING PERMIT
, John /Chris Dover
' 2833 Wilds Lane Northwest
�jNNESO 'c Prior Lake, MN 55372
I Blue City PERMIT NO. / - , 3 7
9524455385 z. Gold city
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
x wads Laxie N tni.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
( O IV WNER dbftii
/ J ri r is .Dcwf (Phone)
(Address) / 2....03 Oh t L 013 uv l V NW
APPLICANT ," ;; i5 ,
(Name) I /' NORBLOM PLUMBING CO. (Phone)
(Address) (612) 827 -4033
(A,d4,e:., GARFIELD AVE. SO. (City) (Zip Code)
(Contact Person) . ' MINNEAPOLIS MN 55408 (Phone)
APPLICANT SIGNATURE .^/ DATE 4126/ / 2-
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher 1 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
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 § 326B.148 ;ost $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $ . 5°
The minimum surcharge for a STATE SURCHARGE $ 4500
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ , 5g
This Application Becomes Your Building Permit When Approved Paid SZ, ripr ipt No. /- - - -73
Date / L I By
Buildine Official Date - +
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245 i
4646 Dakota Street S.E., Prior Lake, Minnesota 55372