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0/ f, t, CIT. O RIOR LAKE PLUMBING PERMIT
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2. Y PERMIT NO . i (o p , � 1 3. Yell ov Applicant r✓✓'
(Please type or print and sign at bottom
ADDRESS / ZONING (office use)
/C / /7r / •, /iv ��" �E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER /�l /� /
(Name) f� r /./ /' " !/ /� (Phone) �� Z '23T /� O
(Address) /777 ,/1'!01-7. 1/;- /(/ F / y ,-- G..4- / ..04111'7Z.-
APPLICANT
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(Name) / % f 6 : / / 4 1 / 2 Z h , —, 6/-- (Phone) o& - .:/ ? �
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(Address) C J . f(� iv / v hrr1. .� -i ��
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(Address) % (City) (Zip Code)
(Contact Person) d frtfre— // (Phone) - /Z fit - -r >`
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APPLICA SIC ATURE .41011111f DATE ���4Z---
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A'iCANT PLEASE COMPLETE BELOW
Quanti Al a of Fixture Quantit T r e of Fixture
BathIP or without shower Rough - ins
Dishwasher Water Heater _
Floor Drain 1 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) j 1 Other 1
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 Est $ Building Permit #
"SURCHARGE" has been changed for one
r'
year effective PLUMBING PERMIT FEE $ - 5----7-4-' �."�
.July 1, 2410, until June 30, 2011. STATE SURCHARGE $ Ste a
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE
is , beginning July 1, 2010 r r t r.• 35_�:l
S5 ;,.
This Application Becomes Your Building Permit When Approved Paid. N 2 1 20 Rece!it No. f
i Date i By ME=
Building Official Date
24 hour notice for all inspections (952) 44 I fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372