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H CITY OF PRIOR LAKE PLUMBING PERMIT Date Rec'd
Gold
2 City
I NNESO
1. rile PERMIT NO. /2_ _ /513d
. Gold
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
5125 Iambi pr. $
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
((Name) w s fi r E [ , 1 S (Phone) Lp 6 J Z t L) ." 6 U I O
(Address) 31125 11 Dr. SW
APPLICANT A L ,,,,�� � 3 /b � /
(Name) ■ At 11 .^ 1 _1 �. . ' * 1*.1 (Phone) q52 4// Ca
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(Address) / . • - A . 1 ■ VC 1 ► ' 5 , "I2- G im %o=s
(Adt ,- ss) (City) (Zip Code)
(Contact Person) a' . - 1 (Phone) G\ 3 o — L — ail
/ /
APPLICANT SIGNATURE « DATE la-tx LIZ
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
The Minnesota Statutes § 326B.148 Est $ Building Permit #
"SURCHARGE" has been extended
until June 30, 2013, PLUMBING PERMIT FEE $
The minimum surcharge for a STATE SURCHARGE $ 50
"fixed fee" permit is $5.00 TOTAL PERMIT FEE $ S4.5D
This Application Becomes Your Building Permit When Approved Paid s i 1 Receipt No. ` 7 737
Date / By ril
Bui lding Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372