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O PRIO ( Date Rec'd
H CITY OF PRIOR LAKE PLUMBING PERMIT
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3 Ylli Fde C ity PERMIT NO. / 3 e / 3�
3 Yellin)/ Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
A q 19 i vakt, ' _ N %1
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PM
OWNER
(Name) (Phone)
(Address)
APPLI i 1 � ® ��� (�
tName)_AI. U I Q - 11,41 l (Phone) Q b2 q6 - -
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(Address) I 1600 Tad F t" .AA. , }) VL N i l Iv)t, '7o l i
(A ss) (City) (Zip Code)
(Contact Person) _ _ i ' . / , ``
7
(Phone) 1012' 7 41 6
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APPLICANT SIGNATURE i1/ll(.[� 'y A �,2�,C�tijLL tt- DATE 1 `- ZCI -. _
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 (Ba throom Sink) Stand Pipe (Washing Machine
Laundry Tray (1 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 § 326B.148 st $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ L a - 50
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ 6 I) O •-,39
The minimum surcharge fora "fixed fee" permit a TOTAL PERMIT FEE $ r-I (4 . EC) is M., beginning July 1, 2010
-
This Application Becomes Your Building Permit When Approved Paid $4 ---` Receipt No. - � � LZ
Building Official Date Date 7/9/4 3 By /
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E, Prior Lake, Minnesota 55372