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?Rep. Date Recd
CITY OF PRIOR LAKE PLUMBING PERMIT
*Nose' 1. Blue File PERMIT NO.
2.Gold City `2-_/, 73
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING office use)
/6030 461_.A erc.c„ic
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
(Name)OWNE1(e-e v 7?Z) 4C
(Phone) Le L < 1 46-
(Address) jZ003
(Name)APPLICANT �e I (Phone)
(Address) 7402 Washington Avenue
Eitma i `-1MN 56344 (City) (Zip Code)
(Contact Person) L_C_- - Phone)
APPLICANT SIGNATURE I I . - DATE z /i�6/i.
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
Estimated Cost $ 0 Building Permit#
The Minnesota Statutes§326B.148
"SURCHARGE"has been extended PLUMBING PERMIT FEE $ t-
until June 30,2013, STATE SURCHARGE $ S OP
The minimum surcharge for a TOTAL PERMIT FEE $ � .
"fixed fee"permit is$5.00
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`T d/. Receipt No.(o J 7 rjl 6
9v,./...1,
Building Official Date Date /4/6_
, /6_ By
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372