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Date Rec'd
pRio�
CITY. , OF PRIOR LAKE PLUMBING PERMIT 10,2-- 1s
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•7IN Q' I. Blue File PERMIT' NO. — ^
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.Gold City i.r��s11v7�311 �t."ejC(-.,
3. Yellow Applicant �'/
(Please type or print and sign at bottom) ZONING(office use)
ADDRESS R I S A
LEGAL DESCRIPTION(office use d -A//o �A6/Q-&.
LOT ` BOCK ��I�ON
OWNER (Phone) 7 ?;`. . `-1 -1 1 . .�;12._:
(Name) )r\ .0 r' .t-'„-.(--..:z.:
(Address) L-1,5 t; z, _
APPLICANT„v � .� a
(Name) _.h,r „ ,,: i?i_.�rr;��;�: 1
(Phone) • •3`1 ')
J _
(Address) jcd ki a
(Address) (City) (Zip Code)
�r (Phone) s :�> I !t
(Contact Person) ?��r- . �,..+� �j
APPLICANT SIGNATURE - f DATE - ,L5 % n
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
'.ost $ Building Permit#
The Minnesota Statutes§326B.148
"SURCHARGE”has been changed for one PLUMBING PERMIT FEE $ .r"t
year effective STATE SURCHARGE $ .50
July 1.2010,until Juni 30.2011. /
" •
The minimum surcharge fora"fixed lee" permit TOTAL PERMIT FEE $ 7'' '
is 35,beginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid 60 SD Receipt No. 502y
iy
Date 1 O 1 <- ByL�Building Official Date `
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372