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4 pRIQ Date Rec'd
°� " h I CITY OF PRIOR LAKE PLUMBING PERMIT q /3, 13
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1. Blue Cif PERMIT NO .
2. Y el l App /9 /Dn ` A
3. Yellow Applicant F-'✓
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
/7 .s 6b,-) 1 1,a /,[r ..j S Rl sly
LEGAL DESCRIPTION (office use only) ?t
LOT BLOCK ADDITION PID 01510/7- 0 / /,`j -d
(Na 16-1 I f'' I ' I t.t, 4 r1 D V i r✓ (Phone) f�,..3 • �� U - --
(Address) / G 7.50 6i ,,, J 1,4 /c • L S 0.-.‘„,- Let /cc. fi2 n .SS3 72 .
APPLICANT
(Name) , L ) el 1J • `i /u rn i0 i i y ...1-- , c, (Phone) 6/- - i,-,14 - )6- 7 , -
(Address) �0 3/ i ' n c -e_ ac,c so - � /91n ._ie !>
(Address) (City) (Zip Code)
(Contact Person /. _ : 1 •. i ' - • ne) 6 /- ` 1 -11 3 .7
APPLICANT SIGNATURE ' -.� DATE 1 S1/4i'
APPLICANT PLEA`
' LETE BELOW
Quantity Type of Fixture uantity 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 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 § 32613.148
1st $ 4w Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $ ��
.July 1, 2010, until June 30, 2011. STATE SURCHARGE $ iP 1
The minimum surcharge for "fixed fee" permit TOTAL PERMIT FEE $ ,/`
J
is IS beginning July 1, 2010 7
This Application Becomes ' our Building Permit When Approved pa J4 CO Receipt No. ,.. I 7
■ I y D !{ �� e B
Build' ■ • a Metal Da f ! ��`
ir Date
. 24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372