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=:_ CITY OF PRIOR LAKE PLUMBING PERMiT ®, HI l
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41I NNSSC il> i. Blue File I PERMIT O . / 3
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS
ZONING (office use)
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LEGAL DESCCRIP ION (office use only)
29_
LOT 6CK ADDITION PID A, " 0/5.-0,0/ - 2
(Nam � lA c,1� �o S ° 1.S Z - (°- B S r7 b
(Name)
(Phone
(Address) , ll- NY\.$
APPLICANT Co V\ �4 t (Phone) q S 2 ` �� S Z 1 i
(Name) , _
(Addres.$)l S 8 8 W ec� VIAY` 4 L S e r S S y
(Address (City) (Zip Code)
(Contact Person) t" &(LL .Yr- -el 0- (Phone) cA.- A.,2 I
Lill 1, c. URE // Al- DATE l n' ` l 13
APPLICANT PLEASE COMPLETE BELOW - LL
: Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower _ Rough -ins
Dishwasher — i _ 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
_. - ' 'MA $ Building Permit #
The Minnesota Statutes ¢ 326B.148 S O
year effective
"SURCHARGE" has been changed for one P LUMBING PERMIT FEE $ 9 July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge for a "fixed fee" permit TOTAL PERMIT FEE $ ' ' \ - So
is 5.i, beginning July 1, 2010
This Application Becomes Y l ur Building Permit When Approved 100' 0' cti „SD Receipt No. ow /S
.11001141 Q 'I V
—
Banding O
• Hate Date t , 11 By
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372