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e CITY OF PRIOR LAKE PLUMBING PERMIT
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I. Blue File
2 Gold city PERMIT NO.�Z , /
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3. Yellow Applicant
(Please type or print and sign at bottom)
ADDRESS ll ZONING (office use)
'1 (v J}U r1(.mi 47 +'` ok I ( q i / AL E
LEGAL DESCRIPTION (office use only)
LOT BLOCK ADDITION PID
OWNER i _I �
(Name)
OWNER ,..- Nra 1o1 Elide/ ) (Phone) 7- �— L 7 8 0
(Address) ii- (nqq I-6 r y vv',` ii b i ed 7t [ / Ail E j P sr 1—c ke ,,Y1A /
APPLICANT— l Q 1 1 1 P( l 5" - $'75 -3 3 7
(Address) 5
(Name) t 1'V� � 1.�4 1 7� l.1 ►N� � Ai (Phone) 99.3 `e r\-1-ceT I AJe v e —J o Mil 5:5 0
—�-- (Address) I (City) (Zip Code)
(Contact Person) 1 t �y tv1Ct k0 (Phone) S`7 VYN e_
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APPLICANT SIGNATURE i . . . ab 01.... 1 t ' DATE 1 /13‘3// d
A' PLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixture Quantity Type of Fixture
Bath Tub with or without shower Rough -ins
Dishwasher I 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
3st $ Building Permit #
The Minnesota Statutes § 326B.148
"SURCHARGE" has been extended PLUMBING PERMIT FEE $
until June 30, 2013, STATE SURCHARGE $ ,5er', bO
The minimum surcharge for a TOTAL PERMIT FEE $ _5
"fixed fee" permit is $5.00
This Application Becomes Your Building Permit When Approved Paid 3¢, 5-11 Recei No. O 4
i
Date By
Buildine Official Date L ' ' / /2_
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372