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C PRI 9 Date Rec'd
9
rivEso OF PRIOR LAKE PLUMBING PERMIT
'NESD� 1. Blue File
2. Gold city PERMIT NO. / 2_, ..13 j
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
1 L oSQ 91bird Trcii
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) h ' h (Phone ` 403 - 67g(4,57
(Address) -- 11, 5S j 9—
01400403A Plumbiing
APPLICANT PC 000308
(Name) (Phone)
651 -665 -13
(Address) 3670 Dodd Road
(Address) Eagan, MN 55123 (City) (Zip Code)
(Contact Person) MTh (Phone)
APPLICANT SIGNATURE Ja i DATE 11 'Co `r'
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
•
Bath Tub with or without shower R
Dishwasher Water Heater
Floor Drain a er - sot ener
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
ost $ f ' Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $
year effective STATE SURCHARGE $ .50
July 1, 2010, until Ju: a 30, 2011.
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ v
is $5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid s4 Receipt No. 4 74 2 3
Building Official Date Date // / / By , ,,
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372
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