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yri,, CITY OF PRIOR LAKE PLUMBING PERMIT , / c./ /3
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PERMIT NO j
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3. Yellow Applicant VV 1L�1
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 Le4 S 1 ay/ \\I OtA) \\I (10
LEGAL DESCRIPTION (office use only)
LOT BLOCK g ADDITION 575 W)/e/2.- ;?t' ( PID ■,- '/4'- OR '- d
OWNER �� Q ^ _ v
(Name) -- L ` (Phone) (1 Z' 5 - $ Y 5 b
(Address) 1M?] L Wo A, N W
APPLIC T
(Name) \ MJ\L 0.4 4 Or (Phone) 9 p 52" O16' 6gt4r)
1 °
(Address) t S '-o P A A , J 'IL' fllit 116 - 11 a 1 I
(Add s) (City) (Zip Code)
(Contact Person) rl (Phone) 6 152-r ° 3
APPLICANT SIGNATURE elk 1 Z � ' . IL: 4 DATE ti - 11-7-0 1..
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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 (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 1 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 extended
until Lune 30, 2013, PLUMBING PERMIT FEE $ 4 1 1 4 56
The minimum surcharge for a STATE SURCHARGE $ OO TO
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ 'S , t
This Application Beco Your Building Permit W en Approved aid , ( �71 Receipt No./� I q .5 —
0 1 C 3 Dal `'� By t(l l
Buildin Olfie Date 113
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24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372