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CITY OF PRIOR LAKE PLUMBING PERMIT
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2. soled city PERMIT NO.// 5Z
3. Yellow Applicant (O ,
(Please type or print and sign at bottom)
ADDRESS ZONING(office use)
15255 Fairway Hti9hi-3 1Zc tow
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER
(Name) 1 OrrCnC t I Qi an 0. 14,1-0 iCA t (Phone) 95 .-LH 7"5373
(Address) 15 g,65 Fatr w cui H c 1 C3'v\i-S - N'AJ
APPLICANT
(Name) ( nailfi Qi0n PiUYNb'ir'19 (Phone) G€ i 3G J 1340
(Address) 3 G,70 Dodd gel ECt.g an , IA 0 5513.3
(Address) (City) (Zip Code)
(Contact Person) 2 e CM/la rt-in -`.-' (Phone)
APPLICANT SIGNATURE �- o DATE i/1g%1
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture •
Bath Tub with or without shower Rou h-ins
Dishwasher 1 ater Heat
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 $ 60,03
year effective
July 1.2010,until Jona 30,2011. STATE SURCHARGE $ .50
The minimum surcharge for a"fixed fee"permit TOTAL PERMIT FEE $ S(1„50
is S5,beginning July 1,2010
This Application Becomes Your Building Permit When Approved Paid 5b ,:61) Receip No. 3 7 q
DateI By 7
Building.Official Date 1. 01 : W
t
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24 hour notice for all inspections(952)447-9350,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372