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,� - CITY OF PRIOR LAKE PLUMBING PERMIT 0 `) /
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41 I� NEsoo fi C/ ----frt i d-a 44(1
1. OoI City P ERMIT NO. /� /13
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS �, t ZONING (office use)
38 9 -7 /uRPe , ,..C)Kiii�
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
(Name) 1 fie l� f� i t (Phone) 4 �� `� �" '� l gQ
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(Address) u �.kek- PAC tl�
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APPLICANT i
(Name) r et $ Wed-el- C i ctN''tcsq (Phone) (oJ`7- 777- "guc�
(Address) 2..2000 /4.-1 y 3 - St TAB ,s> l d L
(Address) (City) (Zip Code)
(Contact Person) Je°t ro e tre- R Q 71 " it (Phone) 6 C I " 7 7 2^ 1 S' vet
APPLICANT SIGNATURE 1. /L 16 it DATE / f l - i3
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"/a of job cost with a $49.50 minimum Residential, New One & Two - Family $149.50
Residential, Additions & Alterations $49.50
The Minnesota Statutes § 326.13.148
" hst $ Building Permit if
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $
is Si, beginning duly 1, 2010
This Application Becomes Your Building Permit When Approved Paid ..6-2,/s .0 Rec No. 701,/
Date ,i d . l3 B .
Building Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372