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` b CITY OF PRIOR LAKE PLUMBING PERMIT
iNNESO 'CP I. Blue File
2. Gold city PERMIT NO. / / /2 /
3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS / Li /6y PArl:viti,J A. /1)k) ZONING (office use)
Pri Lca-2 ` ✓ t∎N 55372
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID ZS 4-37. 0Z D
OWNER
(Name) D 1 X 1i\ F ovA, (Phone) .630' 7S2 - Li 207
(Address) IN PArK'A ,J L Al vi t Prior L -fi MA) ,5, 372.
APPLICANT , /�
(Name) ft \i SAC J . - 4 1 1 pc t . P . T s OF I ' A J (Phone) 9Sa -4 -1 b Ci - $ 3 6 1 I
(Address) lq I OS ► -(d S A).-- PY 6 r 5S
� 1 ( dress) (City) (Zip Code)
(Contact Person) 1 ' «c.1A. ' tll, - , ( Phone ) 9 go -c8 "g
APPLICANT SIGNATURE ,l' lam DATE 16= / 1
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 1/ 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.I48 )St $ 560 - Building Permit #
"SURCHARGE" has been changed for one co
year effective PLUMBING PERMIT FEE $ 51-I.
Jul 1, 2010, until June 30, 2011. STATE SURCHARGE $ .50
The minimum surcharge fora "fixed fee" permit TOTAL PERMIT FEE $ 5
is sf, beginning July 1, 2010
This Application Becomes Your Building Permit When Approved Paid5 / s v Re t No. /_ , / (t. G 6
Building Official Date Date ! / " 0
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372