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/1 CITY ® PRIOR LAKE PLUMBING RING Date l ee'd
INNESO�P
I. Blue File
(Please .e or. ?. cold City PERMIT��
riot and sign at bottom) 3. Yellow /1M-17;4
ADDRESSApplicant
02966 ' /PCi'aC . D//� kl / ZONING(office use)
LEGAL DESCRIPTION(office use only) C.c�l
LOT BLOCK ADDITION
OWNER `- PID
(Name) #' 06,)
(Address) II. Q 11--e'
(Phone) `/s.:.2,-c25-0 —']7 13
'- •.• P • n:
APPLICANT PC 000308
(Name)
(Address) z (Phone)
• 1 L.• • • ; • :;•
Eagent 461 !23
(City) (Zip Code)
(Contact Person)
APPLICANT __ (Phone)
ANT SIGNATURE �,� 1 ' ,
j DATE �62 //p7 (
Quanti APPLICANT PLEASE COMPLETE BELOW
T/•e of Fixture
Bath Tub with or without shower Qaantl T •e of Fixture
Dishwasher ■ Rout
h-ins
IIIIMIIIIIIIIIFloor Drainiliallial
IIIIIINIIIIII
Lavatory(Bathroom Sink) Water Softener
Lauri. Tra (1 or 2 com.artment sink 111111111111111111 Stand Pi•e (Washing Machine)
Shower Stall Sewa•e E'ector
.1111111111111
Backflow Assembl
1111111111111BBar Sink 11111111111111111
-_ Backflow Assembl Test
Water Closet(Toilet)
111111111111 Other
FEE Industrial,Commercial&Multi-family 1%of job cost with a$49.50 minimum Residential,Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
The Minnesota Statutes§326B.148 ost $
"SURCHARGE"has been changedBuilding Permit
yeti effective for one PLUMBING PERMIT FEE $
July 1,2010,until June 3�0,2 STATE SURCHARGE
The minimum surcharge for a eased teepermit $
is 35,beginning July 1,2010 TOTAL I AI,PERMI I FEE SO
$ SU. Sp
This Application Becomes Your Building Permit When Approved Paid
Receipt No.
Building Official Date/} A- /
Y3at ¢, T 16 By jig
•
/ L
24 hour notice for all inspections(952)447-9850,fax(952)447-4245
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372