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1 PRip Date Rec'd
° M CITY OF PRIOR LAKE PLUMBING PERMIT
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Blue Fc P ERMIT NO. f _ O 76/
Ootd cl'iy � J
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PIP
OWNER
(Name) C..„61 - Zen (Phone) 9 - � , j/ — y�
(Address) / 7) / WA-1) f 6sg777 o L
APPLICANT —_l- . S-6)7' q
(Name) J ,�-f \ y, `J \/ �' ��' �hn� yr� r /�G i i1C (Phone) /
(Address) 30.•1 3 '='' Apt_ 1 JS � .
(Address) (City) (Zip Code)
(Contact Person) 14% l' (Phone) �d �� 9sP
APPLICANT SIGNATURE x�"'U�iL,— DATE
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 j 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 I% of joh cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326B.148 Est $ Building Permit #
"SURCHARGE " has been changed for one
year effective PLUMBING PERMIT FEE $ '19,,.J7J
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ ,s-e7
The minimum surcharge fora 'fixed fee" permit TOTAL PERMIT FEE $
is 55, beginning July I, 2010
This Application Becomes Your Building Permit When Approved Pa S l' 1 Receipt No. i ,
Date 7 /j By
Buildins Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372