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o .,,TRI0 � Date Rec'd
E ArVi, CITY OF PRIOR LAKE PLUMBING PERMIT T. g 13
INivES °'c I. Bile File 1 2. Gold City PERMIT NO. /3 - 0 M
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
14 (o81 ear riet e 1---11 - (P a a. t V0 t. 553 R /
Li LEGAL DESCRIPTION (office use only)
LOT 7-BLOCK ‘.9 ADDITION ( f /( / /, -5 Z / 4 / pm aq - 20 0 3 0
OW ER CleDc P 0'1 6 3O J (Phone) YA a- (,c6
(Address) S 0,/(01.6
APPLICANT o _ ,, ( �'?�
(Name) (O
�� � �V �/.l � \�N(1� ( (Phone) ` ' — 51 - _.. (
(Address) N10 OA ‘ li C_.Y1 P 7.
(Address) (City) (Zip Coif!)
(Contact Person) i'V ,— (Phone) l i — �1� V k s ��
APPLICANT SIGNATURE , �� DATE - 9 -Lt
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 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 $ Building Permit #
The Minnesota Statutes § 3268.148 ,,
"SURCHARGE" has been changed for one PLUMBING PERMIT FEE $ tt `41 - 5°
year effective 5 • OG
July 1, 2010. until June 30, 2011. STATE SURCHARGE $
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ 94 - 5
is S5, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid es- / s -- c) Receipt No. ` /, p' 9/
Building Official Date Date 9fh L/4 By (� 1} 7
.G
24 hour notice for all inspections (952) 447 -9350, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372