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4 p0 c., Date Rec'd
N CITY OF PRIOR LAKE PLUMBING PERMIT
,1°--C.'41,04--- t
' flA _` 1. Blue File pERMIT NO .
_'�1VS 2. Gold City /L ` 4/ 7y
3. Yellow Applicant T
(Please type or print and sign at bottom)
ADDRESS ZONING (office rue)
) /rnd h o-
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) R C lfrY / g, ni ,oc_,,..Lv (Phone) I' . < 7 '/
(Address) / 6 (/ `s Jf�cI A, ,-_c_ _ 7....• f 1, •_ ssIS37a„..
APPLICANT t@ritigirE l
(Name) (Phone)
(Address) 7402 Washington Avenue
Edtateativil4PAN ; (City) (Zip Code)
(Contact Person) _ -- _.. • one)
APPLICANT SIGNATURE 1�1 '� � DATE 1 h&a.
• PPLICANT 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
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
Estimated Cost $ :4? « Building Permit #
The Minnesota Statutes § 326B.148 "�
"SURCHARGE" has been extended 'LUMBING PERMIT FEE $ `T
until June 30, 2013, ■TATE SURCHARGE $ 5 .60P
The minimum surcharge for a 'OTAL PERMIT FEE $ ;3 ,5`
"fixed fee" permit is $5.00
i ms Appncanon isecomes x our nuuutng Permit When Approved Paid 4 -7/ g Receipt No. 6 / vo
Date / , 1 7 / 1 _ By () , .1 ..),.... /■ , -
Building Official Date /411 /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372