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CITY OF PRIOR LAKE PLUMBING PERMIT
d'Il'NEse
I. Blue File
z. cola City PERMIT NO. / / /32691
3. Yellow Applicant ,
(Please type or print and sign at bottom)
_(Please
ZONING (office use)
2So4 1>ii4c ewTr.
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER ''ll -- 'J
(Name) 1�V 1 ti a t^ d Je- R 1 kr U C a it (Phone) 55 2 4 ( o 1 5 - ( 2
(Address) 28 0 4 p1 ale V I G Dr
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APPLICANT ��
R (Name) 3/ r at Pro b c l 52 46, i C 7 r "t ✓. (Phone) Q R
S S (-f� -� 5504-4
(Address) � 2 L2 � � l_.1z�V (��e
(Address) (City) (Zip Code)
(Contact Person) . O r k' S�t � (Phone) at 5 Z 4' R <0 q
APPLICANT SIGNAT • j0111111111, 1 • DATE ( Z 8 ' I I
APPLICAN WEASE 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 $ Building Permit #
"SURCHARGE" has been changed for one
year effective PLUMBING PERMIT FEE $
July 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 54
ism, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid S-0 Re t ,..f No. / �,..f b
Date 1 3 - I
Buildine Official Date
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372