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A, Date Rec'd� CITY OF PRIOR LAKE PLUMBING PERMIT
,,,,
41/A NEs(PP
2. BluelFile PERMIT NO. /5—/&78.
3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
tC 4I t 'timber Cres+ Dr 5 P06
LEG41 DESCRIPTION 1� '�{{IPTION(office tis only)
LOT 165L2C) ! J PK "--L� PID46— 471/0-e23-0
OWNER
(Name) eo.rr it DGICKakf (Phone) G ia- 791--iag 1
(Address) 1( 9n 'rimber CrCSf Pr 5
APPLICANT
(Name) Champion Alunnbify3 (Phone) Cast- 3GS - )3N0
(Address) 3G7O Dodd Ld £ucun 551-X3
(Address) (City) (Zip Code)
(Contact Person) fr. I [ s ___ .A (Phone)
APPLICANT SIGNATURE — s '/ DATE 91g5/15
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rou -'ns
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
"SURCI-IARGE"has been changed for one PLUMBING PERMIT FEE $ 50
year effective
Jui., 1.2010,until June 30,2011. STATE SURCHARGE $ .50 ,
The minimum surcharge for a"fixed fee"permit TOTAL PERMIT FEE $ 50.50
is 35,beginning July 1,2010 �f
This Application Becomes Your Building Permit When Approved Paid ° Receipt No. 3,0
Date i r) , -2 ' _. By 5
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