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PRIp{
RIOR LAKE PLUMBING PERMIT(---
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INNESO'
I. Blue File
2. Gold City 110PERMIT N®. f�,��,/_(Please type or print and sign at bottom) 3. Yellow Applicant /. /ADDRESS
5 WppdDU Cte Tr1NU1/ ZON/ING(oi&ce use)
Date Ree'd
� 1LEGAL DESCRIPTION(office use only) /\71
LOT�BLOCK 5 ADDITION � 2/ �(l� c�� PID - 3,j 2l DOWNER
(Name) kyle W i l 1 icxrrLS (Phone) 952,-as0 59(Address) 15 3 9 1�ood buck Tr) N'A1
APPLICANT
(Name) Charhp,ren PiUnethin (Phone) Co51 - 3fo5 -130(Address) 367Q Dodd Rd �agQn , M51x3
(Address) (City)
(Zip Code)
ide
(Contact Person) _ (Phone) G 51- 3G S-i3 Lj U
APPLICANT SIGNATURE '- lf . -�/ DATE 10/'17 f 1
� 5
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture uanti
Q ty Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher I ,���
Floor Drain ZIOVor
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
Industrial,Commercial&Multi-family 1%of job cost with$49.50 minimum LE Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The Minnesota Statutes ti 3268.148 ost $ Building Permit#
"SURCHARGE"has been changed for one
year effective PLUMBING PERMIT FEE $ �(�.�1(j
Tui. 1,2010.until June 30.201 i. STATE SURCHARGE $ .50
The minimum surcharge for a"fixed fee"permit TOTAL PERMIT FEE $
is 35,beginning July 1,2010 50'
This Application Becomes Your Building Permit When Approved Paid
,/b � Receipt Na 3 zo -
Building Official Date By
Date f0.z(. /
3 Z'''''..----
24 hour notice for all inspections(952)44 - l
P 7 9350,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372