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0CITY OF PRIOR LAKE PLUMBING PERMIT
5 e?- 15
'Nr__ 1.Blue File
2. Gold City PERMIT NO. - +rce
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS 1 I r ,^d f •,^TraA(
ZONING i;ofleiceuse)
4r �e , 1,
LEGAL DESCRIPTION(office use only) l , / Y�/
LOT BLOCK / ADDITION K/l C�Fi e.e.A s / yl Q-s Z� b�}PID 41 - . '37'4(20 (.r�
,-,O
OWNER Mark-'v vS/Yr�' ► ti 1��,� U
(Name) � / � (Phone)
(Address) l til 5 -5 L � n tt1....ali-c-r ,'I
APPLICANT N
Oi9t0„ l ?Wm 1JI11 (Phone) ( Ii l 2-) g(2/ -
- o
3
(Address) I 4---1./S S-ei,i0 Av ( v ,--` f04,A...(_ /0
(Address) ( ) '(Zip Code)
A (Phone) ((Contact Person)
�1�) 681, i-- ��
APPLICANT SIGNATURE LIPIIPP DATE iij
,/
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher 1 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 t $ Building Permit#
"SURCHARGE"has been changed for one
year effective PLUMBING PERMIT FEE $ 41.5
July 1,2010,until June 30,2011. STATE SURCHARGE $ 5 O .60
The minimum surcharge for a"fixed fee"permit TOTAL PERMIT FEE $ 6-4/...5.0
is$5,beginning July 1,2010
This Application Becomes Your Building Permit When Approved Pair ' ' Receipt No./AA
Date By S;(4
Buildine Official Date
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372