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°���{ e CITY OF PRIOR LAKE PLUMBING PERMIT
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1. Blue File
2 Gold City PERMIT NO. �, 3 q3
.
3. Yellow Applicant ..
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT if BLOCK 3 ADDITION (,tlt � ernecS ? vt c L 1 ,NP I ,p- bi IQ PID r25 33g- 0a3- 0
OWN � y� � 1 � �, (�L /� l ^
(Nam ) pJ `'1 { 4 Ri"h W.1 i 1 � (Phone) 9 S -i - I V 110 5
(Address) 1 lfG 1 Y6 W Li) , e_ P r` Vy l.k ✓ ._ w 355 I vcate4,
(Name)C . c1 6_,,y. � , 1cA (Phone) ' 715 3a0 ?Irk) l
(Address), 161 10 '11 Cori, illatTn ; ,tf p
T (Addres) (City) (Zip Code)
(Contact Person) 6' S I (Phone) - 1. L 5 ` € ( Q g t O1
APPLICANT SIGNATURE Ali ,/ _ DATE at k.
APPLICANT PLEASE COMPLETE B ELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher Water Heater
Floor Drain I 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 st $ E ' Building 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 fora 'fixed fee" permit TOTAL PERMIT FEE $
is $5, beginning July 1, 2010
This Applic . tion • ■ mes Your Building Per it Wh n Approved ' ) i,v,co Receipt No' r (j ,.,K
.... _ d ate (/ By
.- c /
Bu n Of 117 Date x / 13 Sk 24 hour notice for all inspections (952) 447 -9850, fax (9 2) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372