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/pttz Date Rec'd
/�� CITY OF PRIOR LAKE PLUMBING PERMIT „„
'`NNBS
l ' aa70 F " ° PERMIT NO. L
3 . Y Aip /3'/ !�L3
3. Yellow Applicaol
_(Please typo or print and sign at bottom) j
ADDRESS l L t ” 1 38 0 �„ . C t' rc 1 c t 6 ZONING (office use)
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OName ` �� ( Phone) 1 S Z- 1 1 i- W S L/
(Address) 1 1 3g Orchard 0 rck Ne
APPLICANT a�, C/Y 1 n Z 'on) 3S Z -7( /VW
ame 'hone) l r 2
(Address) 2200 w\ I 1 (k n s Y 1 1 lt 5 S 3 3
(Address) � (City) (Zip �Codde))
(Contact Person) A �� � \ (Phone) 9s Z - 7(9/-1 00(.-.)
APPLICANT SIGNATURE Q /A5t ` / � f3r-e,WL, DATE
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher CD Water Heater
Floor Drain Water Softener
Lavatory (Bathroom Sink) Stand Pipe (Washing Machine)
Laundry Tray (1 or 2 co .' , ailment sink Sewa . e Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet (Toilet) Other
FEE SCHEDULE
Industrial, Commercial & Multi - family I% 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 'MA $ Building Permit #
"SURCHARGE" has been changed for one / S b
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ I Mak'
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ S . SO
is ;, beginning July I, 2010
This Application Becomes Your Building Permit When Approved Paid 3 Receipt No. 74 '/ 0
Building yd....6,L../
Date t 2 / //3 By Building Wilda! Date �f
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372