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OF PRIOR LAKE PLUMBING PERMIT
itMme. .1.� ('�.
'fjMvasoS°' r.alae Fie
i.Gold City PERMIT NO./...s— gj
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
LEGAL DESCRIPTION(ofSce use only)
LOT t BLOCK ADDITION PID
OWNERq
(Name) Lor C...-kk GL c
G -t\c_o (Phone) Qcbl 99(0— i b
(Address) Q,Ct \ E\`t'`e Pk\re S\IJ Cv.o<--.\r-,o,,_`c-t_V'i 3 6' 7-
APPLICANT (Phone),N?0\ aSZ- {(o r 8-34-II
- -1 I
(Name)rl'�P'GP\u,,„,\,-1,,,,, , � Av1L��rC... J —
(Address) q O 7.53Y-4 . t• Y::`\o -v-,o.\‘..- ss-2- r7-z... —
(Address) (City) u C� (Zip Code)
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(Contact Person) % .� � 0` �C► t 6 1..-w� 'hone) c\ — a S‘t
'____,7
APPLICANT SIGNATURE 611, M Y e ' r- —
AP ICANT PLEASE COMPLETE BELOW
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 —,_I
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
"1st $ Building Permit# •
The Minnesota Statutes§32613.148 r
"SURCHARGE"has been changed for one
year effective PLUMBING PERMIT FEE $ "J
O
July 1,2010,until June 30,2011. STATE SURCHARGE $ I 0 0
The minimum surcharge for a"fixed fee"permit TOTAL PERMIT FEE $ 544,50
is 55,beginning July 1,2010
This Application Becomes Your Building Permit When Approved d lr SIC R e nt No.3
fj
Date,,/..• 2.0, \5 By s
Building Official Date �J
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372