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4 Date Rec'd
4, CITY OF PRIOR LAKE PLUMBING PERMIT
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z.t.eld Fileay ..„(i PERMIT NO. /2 121'
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3.Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS L-11 �9S Che--ht- Lt ZONING(office usel
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWN
R
(Name) 'L'( 1 G 1 � � STal C) (Phone) 9 - g40 - /41)
(Address) 'LACI c `-hs-fr)l7-}' 1-1,-,
APPLICANT •
„, ,
(Name) M IJ Pt vrni.t
$ Vic cat- )n). �, (Phone)C3S' 9 Lir y y Li y
(Address) 1920 L-. 314 �4_ J as .•31 -,
(Address) (City) (Zip Code)
(Contact Person) It�NIC. SI,.l 441-)0tC�3O L•4 C Ma ✓ (Phone) $ 1-"-d- V vs- 2/4- 1.-i L/
APPLICANT SIGNATURE DATE
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
The Minnesota Statutes§326B.148 ..?st $ U.� Building Permit#
"SURCHARGE"has been changed for one
year effective PLUMBING PERMIT FEE $ i'CJ .s1)
July 1,2010,until June 30,2011. STATE SURCHARGE $ S. du 'SG—
The minimum surcharge fora"fixed fee"permit TOTAL PERMIT FEE $
is IS beginning July l,2010 �� SI)
This Application Becomes Your Building Permit When Approved Paid,,,c,/ so Receipt No. i ry a
F7.7
Date `�/�772
Building Official Date // .5// .-_ By
i 4...„. ....,
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372